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Co-Sign Visit Chart Notes

August 3, 2015/in Review and Sign Chart Notes, Orders and Documents Review and Sign Chart Notes, Orders and Documents /by Douglas Beagley

If your office uses co-signing, an optional feature in PCC EHR, then some clinicians may require another physician to co-sign their visit chart notes.

First, the user signs the chart themselves, either from within the chart or from the Signing queue.

They must indicate which provider is responsible for co-signing their charts. PCC EHR remembers their last answer and fills it out for them automatically.

Next, the co-signing or supervising physician uses the Signing queue to review a list of charts that require their co-signing.

They can double-click on an entry, review the visit, and click “Co-Sign”.

Both signer and co-signer will be recorded and displayed in the patient’s Visit History, and on the Schedule screen.

The signer can also see, right on the schedule screen, any visits that still require their signature.

Turn On and Configure Co-Signing: You can learn how to turn on and configure co-signing in the PCC EHR Configuration help section.

Phone Encounter Performance Report

August 3, 2015/in Generate Clinical Reports Generate Reports /by Douglas Beagley

You can use the Phone Encounter Performance report to track phone note response time, report on phone tasks, and gather data for PCMH purposes.

First, select Phone Encounter Performance from the Reports menu.


On the Select Criteria window, enter a time and date range and pick one or more phone tasks you wish to research.

What Task Should I Report On?: If you are creating a report for PCMH purposes, select the task that your practice uses to track the first response to the phone note. Your practice may want to create a custom task for this purpose.

Next, click “Generate Report”.

For each phone note with a matching task, PCC EHR displays the date and time when the call was taken and when the first task was completed. Next, you can see the calculated response time and the patient name. If your search didn’t return the tasks you expected, you can click “Back” to return to the criteria selection and try again.

Use the drop-down “Optional Columns” menu to add more information and research the phone tasks.

By adding different columns, you can research user behavior and task usage in more detail.

Click “Save as File” to output the report to a .csv file (comma separated values), suitable for importing into a spreadsheet for further research and reporting. The output file will include any optional columns you chose to display.

Find and Share Patient Education and Handouts

August 3, 2015/in Generate Clinical Reports Generate Reports /by Douglas Beagley

PCC EHR has built-in access to two libraries of patient education resources. The AAP’s Pediatric Patient Education library and the NLM’s MedlinePlus library give you instant access to handouts and current medical information on a wide range of topics.

You can review the materials in the office with families, print it out, save the content to their chart, and share the information through the patient portal.

Find a Handout for a Patient

When you wish to access handouts and other educational materials for a patient, click on the Reports menu and select Patient Education.


To find materials, pick from a list of the patient’s problems and visit diagnoses, prescribed medications, and labs.



You can also use the “All Articles” navigation or the search field to find content.

PDF version of articles: Most articles will have a PDF version available, which you can access by clicking on the PDF icon in the article itself.

As you search for handouts, keep these tips in mind:

  • Search By Lab Tests, Not All Labs: The pull-down search menu for labs displays all known LOINC lab tests your office has on record for the patient. If your labs are not configured with discrete results, you may not see all patient labs. Contact PCC Support for help configuring labs.

  • MedlinePlus Videos and Other Resources: Besides the printable text content, the MedlinePlus and AAP libraries sometimes include video and audio resources. PCC EHR does not support all of these resources, though they may work on your workstation. If you find a video or audio resource on MedlinePlus that you wish to share with a family, you can direct them to http://www.medlineplus.com/ on their own home computer. MedlinePlus is a free service of the U.S. National Library of Medicine.

  • Handouts By Collection: You can jump directly to a particular collection of materials in the AAP’s library by clicking the “Handouts By Collection” link. The AAP patient education library includes Schmitt Pediatric Care Advice, TIPP materials, VIS, Connected Kids, and more.

Print, Save to the Chart, or Send the Handout Through the Patient Portal

One you’ve found a handout or other educational content you want to share with a patient, you can click “Print” under the article title or in the PCC EHR window to give a physical copy to the patient.

You can also click “Save As Document” to add the handout to the patient’s chart and share it through the patient portal.


You can give the handout a new title, set a custom category (the default is “Patient Education”), and even add notes or tasks to the document.

Use the “Display in Portal Documents” checkbox to share the document with Patient Portal users who have access to this patient’s chart. Then families can find it in the “Documents” section for the patient.

Click “Add Portal Message” to immediately create an outgoing patient portal message with the handout as an attachment. You can learn more by reading Receive and Respond to Patient Portal Messages.

Set a New Default Category: You can set a default document category for patient education that will auto populate the Edit Tags window. You can find this in the Patient Education tab of the Document Administration tool in the Tools menu.

Access Other AAP Resources Through the Patient Education Tool

As part of PCC’s agreement with the AAP, the Patient Education tool also provides access to the Pediatric Red Book and the AAP Pediatric Coding Newsletter.


You can also access these AAP resources by logging in to PCCTalk.

Switch Between AAP Materials and MedlinePlus Materials

By default, PCC EHR will display the AAP Pediatric Patient Education library first. You can select the MedLinePlus library instead, and PCC EHR will remember your preference.


Both MedlinePlus and the AAP Pediatric Patient Education resources will open on an “All Handouts” library page, making it easy to find relevant materials.

AAP Text Search vs. MedlinePlus Codes: When you select patient criteria from the pull-down menu, PCC EHR searches for that criteria in the AAP library. When you select patient criteria to search the MedlinePlus library, PCC EHR submits the actual SNOMED codes for each item. For this reason, you may find more exact matches in MedlinePlus.

How to Track Patient Education for Meaningful Use

If your practice is tracking the distribution of educational materials in order to meet Meaningful Use, you must:

  1. Use the Patient Education tool found in the Reports menu of PCC EHR.
  2. Select a problem, diagnosis, medication, or lab test from the patient criteria drop-down list.
  3. Select a handout or article from the list found, or perform a secondary search.
  4. Click either the “Print” or “Save As Document” buttons.

These options are covered in the first two sections of this article, above.

By first selecting from the pull-down list to find patient relevant materials, and then printing the handout (or saving it as a document and sending it via the patient portal), PCC EHR can track that you provided the education materials according to Meaningful Use guidelines.

Patient Visit Summary Report

August 3, 2015/in Generate Clinical Reports Generate Reports /by Douglas Beagley

The Patient Visit Summary is an “end-of-visit” clinical summary report. It details everything that happened during an appointment or other encounter. The report optionally includes an overview of other patient medical information. You can also customize what appears on the report and configure special components which will include patient instructions and other information.

This report is a feature required for HHS ONC certification, and by providing it you meet a Meaningful Use Measure.

Generate the Patient Visit Summary Report

While reviewing a chart note click the Print button at the top to open the report and automatically select that visit.

Alternatively, after you open a patient chart (or phone note, portal message, or other message protocol), select “Patient Visit Summary” from the Reports menu.

Select Options For the Patient Visit Summary

Before you generate the report, you can select the visit encounter (if other than today) and optionally change what information will appear on the report output.

Your practice’s default settings will appear, and you can add or remove items using the checkboxes in the Customize panel on the left-hand side of the window. For example, you can decide to add or remove Medications, Vitals, or other visit information based on whether or not that information is relevant to the visit.

As you make changes, the report preview will display a text-only view of the report’s contents. Report attachments, such as the patient care plans, will not appear in the preview.

Hidden Diagnoses in the Patient Chart: Any diagnoses that are hidden or “locked” will not display in the Patient Visit Summary. To get a report that contains these diagnoses, use the Summary of Care Record.

Display ICD-10 for Referral or Lab Requisitions: Some practices use the Patient Visit Summary to help communicate about an order. For example, you might use it as a lab requisition form. As you customize what appears on the report, you can indicate that it should include the Diagnoses, along with the ICD-10 codes, to help communicate to a third party or biller.

Save or Print the Report

After you select options for the report, click “Save as…” or “Print” to output the Patient Visit Summary.

If you select print, your computer’s standard print dialog window will open. If you select “Save as…” option, you will be prompted to save the PDF. You can later attach the PDF to portal message, an e-mail, or similar.

Export the Report as a C-CDA File

Your practice can also save a Patient Visit Summary in the C-CDA Clinical Summary xml file format for transmission to other medical practices.

When you generate a Patient Visit Summary, click “Save as…” to create a file. In the file type pull-down menu, you can choose either a PDF file or a C-CDA xml file.


Configuration, Include, Exclude: Your practice can set report defaults and make modifications to what appears in the Patient Visit Summary. The C-CDA will reflect your changes. Labs and orders that are marked to be private and not appear on patient reports will not be included in the C-CDA file.

Record that a Patient’s Family Declined the Patient Visit Summary

You can record when a patient or guardian declined to receive a Patient Visit Summary report for the day’s appointment.

Click on the Decline button to indicate the patient or guardian did not want the Patient Visit Summary.

Alternatively, you can click Decline inside the Patient Visit Summary window.

Why Would You Record That a Family Declined the Patient Visit Summary?: In order to meet Meaningful Use benchmarks or other mandate programs, your practice mght offer a Patient Visit Summary for each visit. Since the family may say, “no thanks”, you can click “Decline” to record their refusal and save the paper and ink for the report. PCC EHR will record the act of declining the report in the chart’s background event log. Your results on the Meaningful Use report will indicate that the family was offered the report.

Configure the Patient Visit Summary Report

Use the Patient Visit Summary Configuration tool to configure what will appear on the Patient Visit Summary by default.


Configure Which Office Contact Information Should Appear

First, you can set what location information should appear at the top of the visit summary. Should your practice’s location information appear, or the information for the visit’s scheduled location?


Configure Your Addresses: Contact PCC Support for help updating your practice’s addresses.

Configure Problem List Notes

If your visit summary is going to include the patient’s problems from the Problem List, you can indicate whether the problem notes should appear as well.


Customize Other Report Content

You can configure what visit information and other patient information should appear on the visit summary.

For example, your practice may want future appointments and orders to appear, but you may decide that allergies and care plan information should not appear on the default Patient Visit Summary. Also, if your practice uses the Patient Visit Summary as a lab requisition form, or to communicate encounter information with other third-parties, you may want to check the “Display ICD-10” checkbox.

Customization Does Not Override Confidential Orders: The customization features allow you to display or hide orders from the Patient Visit Summary report. However, if a specific order’s “Include on Patient Reports” checkbox is deselected, that order will not appear on the Patient Visit Summary even when Orders are selected.

Configure Chief Complaint and Clinical Instructions

If you would like the visit’s Chief Complaint or Clinical Instructions to appear on the Patient Visit Summary report, you must configure which chart note components your practice uses to track that information during a visit.

In the example above, the practice indicated that any charted information in the generic Chief Complaint or custom “Chief Complaint–asthma” components should appear as the patient’s Chief Complaint on the Patient Visit Summary report. The practice has also indicated two different Plan components that should appear as Clinical Instructions.

You can add or remove any chart note components that you would like to appear on the Patient Visit Summary report as Chief Complaint or as Clinical Instructions. When you generate the report, PCC EHR will use any information it finds in the assigned components for the visit.

Charting Overview

August 3, 2015/in Get Started Chart a Visit Chart a Visit /by Douglas Beagley

If a patient has an appointment today, or a provider has opened a chart note using the Visit History chart section, visit-related buttons for charting appear under the “Visit” headline in the lower- left navigation of the chart.

Click on a chart note title to open it. You will see the chart note’s custom navigation buttons.

Use the chart note navigation buttons to browse the chart note and begin entering information about the exam.

Chart note protocols are made up of different components, and you can create different protocols for different visit types and (optionally) for each provider. A typical chart note protocols might contain vitals, history, SOAP sections, and sections for creating orders.

As clinicians enter vitals, select diagnoses and procedures, or enter and fulfill labs, orders, and prescriptions, the PCC EHR automatically adds that information to the patient’s historical record. Any information you mark in a chart note will later appear on the Visit History screen.

When finished, providers click “Save” to save their work and click “Schedule” to return to the schedule.

Multiple nurses and other clinicians may open, edit, close, and reopen a patient’s chart and contribute to the details of a visit.

When the encounter is finished, a clinician can click “Bill” to review billed diagnoses, add additional procedures, and make the encounter ready for billing. They can then finish charting and sign the chart note.

Refresh and Conflicts: If multiple users in your office open and make changes to a patient chart, then the “Save + Refresh” button will turn yellow. Click the button to save your own changes and display any changes made by other users. PCC EHR records changes to a patient chart independently, by user; multiple changes can not conflict.

Chart Note Navigation

When charting a visit, each button on the left corresponds with an anchor point on the chart note. You can navigate through a chart note in three ways:

  1. Click the anchor buttons to jump to particular sections of the chart note.

  2. Scroll up and down using the scroll bar.

  3. Use the “Next” and “Previous” buttons to step through each section of the chart note.

Configure Diagnoses in PCC EHR

August 3, 2015/in Configure Other PCC EHR Features Configure PCC EHR /by Douglas Beagley

Clinicians can select diagnoses on a chart note, or add a new diagnosis to a patient’s Problem List. Read the sections below to learn how to configure how diagnoses are recorded.

Diagnoses In PCC EHR

PCC EHR chart notes, problem lists, and allergy lists use the SNOMED-CT standard to describe patient diagnoses. When a physician records a diagnosis in a chart, they search from a customizable “Favorites” list, which is a subset of the full SNOMED-CT list. They can also search the full SNOMED-CT list. PCC’s answer memory and other features help clinicians quickly select the correct diagnoses.

SNOMED-CT diagnoses allow physicians to create detailed, precise descriptions of a patient’s condition. Additionally, when you use SNOMED terms you meet requirements for PCMH, the EHR Medicaid Incentive Program, and related incentive measures.

Use the Diagnosis Configuration tool to customize the searchable lists of diagnoses for different components in PCC EHR. You can also review and configure your SNOMED favorites and choose from alternate descriptions.

What About ICD-10 and Billing Codes?: Use the Diagnosis Configuration tool to manage the lists of SNOMED diagnoses used in the patient chart. Use the Billing Configuration tool to configure billing codes.

SNOMED-CT Updates: The SNOMED-CT library is updated periodically with corrections, name changes, and new or deprecated diagnoses. PCC reviews and applies these updates to your PCC EHR system during a software update. If a diagnosis description changes, PCC preserves the charted diagnosis as it was shown when diagnosed during a visit. Diagnoses on a Problem List, however, will reflect the most recent standardized description of the code.

Open the Diagnosis Configuration Tool

Select “Diagnoses” from the Configuration menu to work with diagnoses.


From the Diagnosis Configuration window, you can review diagnosis settings, SNOMED text descriptions, and alternate descriptions. You can use the search tools, Display filter, and Columns menu to isolate the diagnoses you wish to configure.

Display: Click on one of the “Display” options to filter the list to favorite diagnoses, allergies, Family Hx items, or All Diagnosis (the master list of SNOMED diagnosis descriptions).

Customize Columns: Use the Columns drop-down menu to customize which columns appear.

Search and Browse: You can search for a diagnosis using the Search field, and use the Page Up and Page Down buttons to look through the results.

Configure Favorites, Allergies, and Family Hx Items

Use the first three columns in the Diagnosis Configuration tool to designate a diagnosis as a Favorite, Allergy, or Family History related diagnosis. You can use the Display filter option to work with one of these lists.

These three lists of diagnoses control which descriptions will be selectable or easily searched from drop-down menus in components in the chart. A user can always perform a deeper search by right-clicking on a diagnosis field, but the Favorite, Allergy, and Family History sets of diagnoses make finding and entering diagnoses faster and easier for the clinician.

Your Practice's Starting Lists: PCC installs an initial list of Favorites, Allergies, and Family History items based on recommendations from pediatricians. You can use the checkboxes to add or remove selections to meet your practice’s needs.

Your Practice's Lists Will Grow Automatically: When you add a new diagnosis to a patient’s chart, PCC EHR automatically remembers it as a practice Favorite so it will be easier to find next time. For example, if you right-clicked on the Problem List and searched for an usual diagnosis, that diagnosis would be added to the Favorites list so the next time a clinician needed it, they could simply begin typing the description.

The display buttons at the bottom allow you to quickly review just your favorites, allergies, or family history items so you can review those lists and confirm their descriptions and mapped billing code.

Diagnoses with "Family History" in the Description: Some SNOMED descriptions include “Family History” language, such as “Family History Cancer”. PCC recommends that offices do not use those items in the Family Medical History component, to avoid confusion. They are appropriate for diagnosing a patient.

Edit Diagnoses

Double-click on a diagnosis description to review settings and alternate descriptions.


Preferred Description

The SNOMED library includes some alternate descriptions. You can use the pull-down menu to pick a different term, which may make it easier to search for that term from a patient’s chart or the Problem List.

Example: Make Common Diagnoses Searchable By Acronym

The SNOMED library includes some alternate descriptions that contain acronyms. You can use the Diagnosis Configuration tool to make searching for those common diagnoses easier for your clinicians.

For example, your physicians may want to type “UTI” instead of typing out “Urinary” to find the simplest Urinary Tract Infection diagnosis description.

First, open the Diagnosis Configuration tool and search for the common diagnosis.


Next, double-click on a diagnosis to set your preferred description.


After selecting an alternate description, your physicians will be able to find it by typing a few letters in any diagnosis field in PCC EHR. For an acronym, that means that typing UTI and pressing Enter will select the common UTI SNOMED description.

In addition to UTI, some common SNOMED descriptions with an acronym option include:

  • Acute Upper Respiratory respiratory (URI)
  • Upper Respiratory (URI)
  • Otitis Media (OM)
  • Attention Deficient Hyperactivity Syndrome (ADHD)
  • Urinary Tract Infection (UTI)
  • Acute Otitis Media (AOM)
  • Acute suppurative otitis media (ASOM)

Note that if your practice uses these acronyms, clinicians may be less likely to use the more detailed versions of the descriptions available in SNOMED. For the full range of urinary tract infection descriptions on your practice’s favorite list, for example, a physician can begin typing “urinary”:

Billing Diagnosis Configuration

In addition to setting up diagnosis searching and descriptions, you can also configure billing diagnoses.

For example, you can specify which ICD-9 or ICD-10 code will be billed for each diagnosis description, and you can specify which billing code will appear when a medical procedure is performed.

Read the Billing Configuration help article to learn more.

Clinical Alerts

August 3, 2015/in Configure Other PCC EHR Features Configure PCC EHR /by Douglas Beagley

PCC EHR can alert you about specific clinical concerns, based on a patient’s demographics, diagnoses, or other complex criteria combinations.

Watch a Video: Want to watch a video that will teach you how to use these features? CLICK HERE.

What is a Clinical Alert?

When you check in a patient, open or save their chart, or begin to schedule them in the Appointment Book, you may see clinical alerts that pertain to the patient:

Your office can create unlimited clinical alerts, based on a wide range of criteria.

  • Alert when the family checks in, and needs to fill out some missing paperwork
  • Alert when the family has a billing problem, or has another account status flag that may need attention before you proceed
  • Alert when the patient has certain diagnoses, such as diabetes or asthma, so the provider will review the issue
  • Alert when the patient is “Chronic” or has other special status flags
  • Alert that a flu shot is recommended, for patients who match certain criteria
  • Alert for medication concerns, based on the patient’s medication record and diagnoses

You can also configure clinical alerts to appear only for users with certain assigned roles. By creating custom roles and alerts based on roles, you could ensure that medical based alerts appeared only for clinicians, for example, or design a different set of alerts for different sets of users.

Open Clinical Alerts Configuration and Review Your Practice’s Alerts

Click on the Configuration menu and select Clinical Alerts.


You can see the name of each alert and whether or not it is active.

Click “Add” to create a new alert. Select any alert and click “Delete” to remove it or “Edit” to make changes.

Why Not Active?: Your office may have seasonal flu reminder alerts or other alerts that you create and configure but later turn on or off, depending on the time of year or other concerns. Review the “Create or Edit a Clinical Alert” section below to learn about activating or deactivating an alert or determining when it should appear.

Permissions: Only specified users may access the Clinical Alerts tool. If you do not have access to the Clinical Alerts tool, contact your practice’s PCC EHR system administrator or PCC Support.

Create or Edit a Clinical Alert

Click “Add” to create a new alert from scratch. Or select an alert and click “Edit”.


In the Edit Alert window, you can edit basic settings, the text and source of the alert message, and the different criteria that cause the alert to appear.

Basic Alert Settings

When creating or editing an alert, enter the following items:

      • Alert Name and Alert Message: Enter or edit the alert’s name and the text that will appear when the alert is triggered.

      • Present this Alert when: When does the alert appear? Choose whether to trigger the alert when the patient’s chart is opened or saved, when the patient is checked in using the Patient Check-In component, and/or when the patient is found for scheduling. If none of these options is selected, the alert will be “Inactive”. You can create alerts and activate or deactivate them based on seasonal issues.

      • Present this Alert to: Who sees the alert? Use the pull down menu to select user roles for users who should see the alert, if the patient matches the criteria.

      • Time Range for Criteria: Set the general time frame for all the criteria that apply to the alert.

    If you want an alert for a poor BMI, you would use the criteria for “Today”. If you are checking for a drug and diagnosis conflict, or creating an asthma alert, it may be relevant if the patient has ever had a diagnosis. You would select “From patient’s birth through today”. For other circumstances, you can specify a date range for when the criteria should be true to trigger the alert. For example, you may wish to have the alert appear for patients who had certain lab test results in the past six months.

    Criteria

    The criteria section determines which patient charts will display the alert.

    You can add criteria in a number of different categories.

    Choose a category and then click “Add” or “Edit” to configure criteria. For example, if you wanted to include all patients with specific lab test results, you would add a Lab Test Results criteria.


    As you enter the details for a new criteria, new blank lines will appear below for adding additional “OR” criteria in that section.

    Here are some other tips and helpful details about specific Clinical Alerts criteria:

    • Where's the Lab Test I Need?: When you create a Clinical Alert based on a lab test, the pull-down menu will offer all the tests for which your practice has ever had a result. Rather than display all possible LOINC tests, the interface uses the tests that your practice uses.

    • Demographics and Vitals: When you add a demographics or vitals criteria, the screen will prompt you to first select a specific criterion (age, height, etc) and then click Add to create criteria.


    • Chronic, and Other Patient Flags: Does your office use patient status flags to classify patients with certain needs? You can create a clinical alert for all patients with a specified flag. Use the Patient Status field (found in the Demographics section of a chart) to add a status flag to a patient, then use the Patient Status criteria for your clinical alert. If you want to create a clinical alert for a new status you’ve never tracked before, first create the status in the Table Editor (ted configuration tool in Practice Management.

    • Billing Issues and Other Account Flags: Before you schedule a patient in the Appointment Book, you may want to know if the patient has an outstanding billing issue. You can use the Status Flags criteria (also found in the Demographics section), to identify flags such as “Billing Problem”.

    • Select Patients Under a Percentile: For Vitals criteria, you can add values based on percentiles, such as patients under a certain percentile for weight or height.

    • Deceased Status: Use the Deceased patient status criteria to exclude deceased patients from triggering clinical alerts, where appropriate. You can find it in the Demographics criteria section.

By mixing and matching criteria, you can build a complex combination of rules that will provide the right alert for your users when they save and/or open the patient chart.

Clinical Reference

In addition to your custom alert text, PCC EHR can display resource links related to a clinical alert’s criteria. You can configure your alerts to display resources based on items in the patient’s Problem List, Medication History, or laboratory tests and results.

For example, a clinical alert about a disease diagnosis may provide links to additional information about that disease. Or, if the patient had a particular medication, an alert based on that medication can include a link to drug information.When you see a clinical reference, click on a topic to learn more.


While viewing a clinical reference, you can use the drop-down menu at the top to select a different reference topic for the patient.

Source

Optionally, you can enter a source or other attribution for the alert message.


Clinical Alerts Activity Log

The Clinical Alerts tool includes an Activity Log, allowing you to track when a clinical alert was turned on, modified, or turned off.

Open the Clinical Alerts tool from the Tools menu.


Use the new Activity Log tab to review when a clinical alert was active, or to see which clinical alerts were active during a specified date range. This information will help you meet the Clinical Decision Support measure for Meaningful Use.

Log In to PCC EHR

August 3, 2015/in Get Started in PCC EHR Get Started in PCC EHR /by Douglas Beagley

Follow the procedure below to log in to the PCC EHR.

Double-Click on PCC EHR Icon

Start PCC EHR by double-clicking on the icon or selecting PCC EHR from the Start menu.


Enter Your Username and Password

If you do not remember your username or password, contact your office’s system administrator.


Select Your Location, Optionally Set It As Default

If your practice has multiple locations, and you have not already set a default location, PCC EHR will ask you what location you are working for today.

You can deselect the “Ask for my location each time…” checkbox to set the location as your new default. Later, you can adjust these settings in the My Account tool in the File menu.

Begin to See Patients or Review Charts

The first screen of PCC EHR shows today’s schedule. By default, it will show all appointments, for today, for all providers. Double-click on any patient to open their chart, or use the Find search box to find any patient and open their chart.

Click on a queue to view lists of tasks, messages, and perform other functions.

Click a navigation button to open other tools, like the Appointment Book, Import Documents, or Practice Management.

Concurrent Access

You can log in to PCC EHR from multiple computers around your office, and different users can access and add information to a patient’s chart at the same time. However, a single user can not open the same chart twice at the same time.

If you attempt to open the same chart a second time, PCC EHR will prompt you to save your changes and close the chart elsewhere, discard any changes, or cancel and leave the chart open on your other login or screen.

Sign Visit Chart Notes

August 3, 2015/in Review and Sign Chart Notes, Orders and Documents Review and Sign Chart Notes, Orders and Documents /by Douglas Beagley

Many providers signal that they are finished with a chart by “signing” their work. You can sign a chart note by clicking the “Sign” button at the bottom of the chart note screen.


You can also find unsigned visits and sign them on the Signing queue.

Double-click on a visit, then review and sign the chart note using the Sign Visit pop-up window.

On the Sign Visit pop-up window, you can review the chart note, just as it appears in the Visit History, jump into the full chart if necessary, and click “Sign” to sign the note.

Changing a Chart Note After Signing: Providers may continue to open the chart notes and make changes after it has been signed. A chart can be signed multiple times, by multiple people. PCC EHR tracks who signed a note and when it was signed. You can review the signed status in the header of the chart note.

Multiple Signers: If multiple providers sign a chart note, or if the same provider signs and re-signs a chart, PCC EHR will record all signatures in the Visit History.

Signing Permissions: Only users with “Signing” access permissions may sign charts, documents, or other items.

Signing Status on the Schedule Screen: You can also see what visits need to be signed right on the schedule screen by looking at the “Signed” column. This column is blank for unsigned visits. If a visit has been signed, the names of all signers will appear here. Visits that need to be co-signed display the required co-signer’s name in orange.

Configure Order Billing, Diagnoses, and the Bill Window

August 3, 2015/in Configure Billing Functions Configure Billing Functions /by Douglas Beagley

Use the Billing Configuration tool in PCC EHR to configure billing behaviors of procedures and diagnoses. You can map chart diagnoses (SNOMED-CT) to billing diagnoses (ICD-10), customize which diagnoses and billing procedures are triggered by each order, customize the clinician’s Bill window for ease of use, and more.

Introduction: How is work prepared for billing?

As a clinician charts a visit, they add orders, procedures, and diagnoses to the chart note. Based on your configuration, PCC EHR automatically adds appropriate diagnosis and procedure codes to the encounter. Clinicians then click the “Bill” button at any time to visit the Bill window. (The Bill window is also called the “Electronic Encounter Form” or “EEF”, as before EHRs and EMRs some clinicians used a paper “Encounter Form” to select billing codes.)

In the Bill window, the clinician can see what has been coded for an encounter so far, make changes, add additional billing codes (select a visit level), link procedures and diagnoses, and then approve the visit for billing. (Read Prepare an Encounter for Billing to learn more.)

Your practice can use the Billing Configuration tool in PCC EHR to control all of these billing behaviors. For example, you can configure codes for orders; configure the mapping between diagnosis descriptions, which are in SNOMED-CT terms, and ICD-10 billing codes; and adjust the default procedures (like 99213 and other visit codes) that appear on the Bill window. You can also set up “optional” codes for orders, and make use of other custom configuration options to streamline the PCC EHR workflow for your practice.

Here are some notes to keep in mind as you use the Billing Configuration tool:

  • Changes Only Affect Future Visits, Not the Past: When you make to your billing configuration and electronic encounter form, previous billed visits will not lose information. For example, you could change what procedures are triggered by an order, and that change will only affect future orders. Similarly, old visit encounter forms will display whatever was billed at the time and not reflect any configuration changes.

  • User Access: Permission to use the Billing Configuration configuration tool is controlled in the User Administration tool. Contact your system administrator if you can not run the tool. To prevent over-writing each other’s work, the Billing Configuration tool can only be opened by a single user at a time.

  • ICD-9 and ICD-10 Compatible: Some of the examples below display ICD-9 and ICD-10 codes. All features of PCC EHR work with both ICD-9 and ICD-10. A few years after the ICD-10 transition, PCC removed ICD-9 as a configuration option, but a patient’s old ICD-9 charge records will still display in charge histories and on charts.

Configure the Procedure Billing Code Mapping for Each Order

When you create an order for a patient, procedure codes and diagnoses can be automatically added to the Bill window for the encounter. Use the first tab of the Billing Configuration tool to configure which billing codes your labs and other orders will trigger by default. You can also set optional, selectable procedures.

Why Do This?: When you indicate a diagnosis on a patient’s chart note, it appears on the Bill window for the encounter automatically. Orders, labs, and medical procedures require one or more procedure billing codes (usually CPT codes), and may also have optional codes based on the situation.

Follow this procedure to configure which billing codes are triggered by an order.

Open the Billing Configuration Tool from the Configuration Menu

From anywhere in PCC EHR, click on the Configuration menu and select “Billing”.


Select “Order Mapping”

Click on the first tab, “Order Mapping” to view order mapping.

Find an Order

Use the Search Filter to find an order or group of orders to edit.

Double-click on an order to edit the billing codes.

Note: You can create new labs in the Lab Configuration Tool. You can create orders for followups, handouts, new medical procedures, medical tests, radiology, referrals, screenings, supplies, and surgical procedures in the Component Builder in the Protocol Configuration tool. The list of available immunization orders comes from under-the-hood configuration. Contact PCC Support for help with order configuration or for help adding new vaccines.

Add the Order’s Procedure Billing Codes (and Optionally Diagnosis Codes)

Next, add one or more procedure billing codes. These are typically CPT codes. Optionally, you can also add a billing diagnosis code.

You can start typing in a field to search and then select from the pull-down menu. You can click the plus sign (+) to add additional codes. PCC EHR will not allow you to select a billing code that has expired (due to an ICD-10 code update, for example), but you can add codes that will be valid in the future.

Automatic Diagnosis Codes Should Be Rare: Clinicians enter diagnoses on a patient’s chart note. If you configure an order to automatically trigger a billing diagnosis, it will not appear on the chart note and will be difficult to track in the patient’s record. However, certain procedures, such as ear piercing or the Z23 immunization diagnoses (as shown above), do not appear on a chart note but are required for reimbursement from an insurance company.

Optional: Add “Optional” Codes

The “Pre-Select on Billing Screen” option will be selected by default when you add a code. That means that whenever the order is made, the code will appear on the Bill window, pre-selected. If you deselect this option, then the codes will appear unselected.

Use this feature when an order may or may not require a certain billing code. The clinician can then decide whether or not to send the billing code on-the-fly, while billing.

Optional: Continue to the Other Tabs to Configure Other Billing Options

After working on your orders, you may want to make revisions to diagnosis code mapping or to the diagnoses and procedures that will always appear on the encounter form. Click on the other tabs to review other billing settings.

See the procedures below for complete instructions.

Click “Save”

Click the Save button to save your work and close the Billing Configuration tool.

Test Your Changes

Next, create a visit for a test patient and then create the order on the chart note. Click “Bill” to see if the correct billing codes appear.


Link Chart Diagnoses to ICD-10 Billing Codes

When the clinician selects a diagnosis on a chart note, they use SNOMED-CT. PCC EHR automatically selects an appropriate ICD-10 billing diagnosis and adds it to the visit’s Bill window for billing.

Use the Diagnosis Mapping tab in the Billing Configuration tool to specify which ICD-10 billing diagnoses will be added to the encounter form for each SNOMED-CT diagnosis description.


Use the Search Filter to find a diagnosis, and double-click on any description to make changes.

When you edit a diagnosis, you can adjust the corresponding ICD-10 billing codes. When a clinician selects the diagnosis on a patient’s chart, what ICD-10 code will appear on the claim?


PCC EHR will not allow you to select a billing code that has expired (due to an ICD-10 code update, for example), but you can add codes that will be valid in the future.

Assisted Mapping, Manual Mapping Options

When available, the Diagnosis Configuration tool will display an “assisted mapping” option. The assisted mapping option describes any patient details or coding conventions that will determine the code. It then lists all possible ICD-10 codes for the given diagnosis description.

PCC’s ICD-10 assisted mapping comes from the National Library of Medicine. Your practice can switch to a manual mapping code to suit your billing needs.

There may also be diagnoses with no available mapped ICD-10 code. When there is no assisted mapping option, you can use the manual mapping option to set the billing diagnoses.

You Can Also Change Codes Later, On a Case-by-Case Basis: Regardless of the assisted mapping or manual mapping settings, your practice can change the billing code later. Clinicians can select diagnoses on the Bill window and billers can make changes later when they post charges. Diagnosis Mapping sets the default code that appears when a clinician first selects a diagnosis.

Map Multiple, Optional ICD-10 Billing Codes to a Single Diagnosis

You can configure multiple ICD-10 mapping options for any SNOMED diagnosis description.

When your practice decides that a SNOMED diagnosis description needs a list of optional ICD-10 billing codes, use the Manual mapping section to add to or edit a list of ICD-10s.

You can select the “Preselect” checkbox for one or more ICD-10 codes. If set to “Preselect”, that ICD-10 code will be added to the visit automatically when the user selects the SNOMED-CT diagnosis on the chart note. Otherwise, it will be available through a drop-down menu.

For example, your practice may want a certain ICD-10 to be preselected automatically, but allow the clinician or biller to adjust it to one of several other options that are not preselected. You can use the ICD-10 manual mapping features to create a pick-list for the clinician.

Update Previous Work-Arounds: Before the PCC 7.3 (April 2016) update, your practice may have used different SNOMED-CT descriptions to indicate well visits, mapping them for with/without abnormal findings. You may also have created Electronic Encounter Form shortcuts for BMI reporting or made different mapping options available for recording prematurity. You can now use the multiple-mapping option to reconfigure your diagnoses and your billing screens to use the new, optional mapping features.

Add Selectable Procedures to the Bill Window (Electronic Encounter Form)

As you chart a patient’s visit, PCC EHR adds diagnoses and procedures to the Bill window (sometimes called the Electronic Encounter Form, or EEF.) The Bill window can also display your practice’s list of common visit procedures, such as E&M visit codes, telemedicine encounter codes, or other billing codes that a clinician needs to select.

Follow the procedure below to use the Billing Configuration tool to modify the Procedures list and make it more useful for your practice.

Open the Billing Configuration Tool from the Configuration Menu

From anywhere in PCC EHR, click on the Configuration menu and select “Billing”.

Select a Tab to Edit Procedures (or Diagnoses)

Click on one of the section tabs to edit either the Default Procedures or Default Diagnoses section of the encounter form.


Find an Item, or Type a Custom Heading Name

Use the search field at the top to find a procedure (or diagnosis). You can search by name or code.

If you wish to add a non-selectable heading, for organizing items on the screen into categories, enter your heading label in the second field.


  • Well Visits: You do not need to add each of the age-appropriate Well Child procedures to your encounter form. Add the “Well Child (Age Auto-Calculated)” entry instead, and the corresponding “New Well Child (Age Auto-Calculated)”. PCC EHR will adjust the Bill window to reflect the patient’s age each new visit.

  • Can't Find It?: If you can’t find the procedure or diagnosis you are looking for, first double-check that you are working in the correct tab (Diagnoses, Procedures) of the Encounter Form Editor. Next, check the Procedures table in the Tables tool.

  • Multiple Units or Special Procedures?: If you need to regularly order a special procedure or multiple unit procedure, you may decide to create new entries in the Procedures table. Some offices use billing procedure entries to make it easy to select multiple administrations or to indicate the need for a follow-up visit, for example.

Click “Add”

Diagnoses: In order to keep a complete patient record, physicians should enter diagnoses on the chart note. All charted diagnoses are automatically added to the Bill window with their corresponding ICD-10 billing code. It is possible to manually enter new diagnoses on the Bill window, as a message to your checkout or billing staff, but those items will not become part of the patient’s medical record.

Click and Drag Items to Desired Locations

New items appear in the lower-left corner of the list. Click on the drag handle and move any item to a new location.

Two Columns: Note that there are two columns on the screen. You may click and drag items between the two columns.

Optional: Delete Items

Click on any item and then click “Delete” to remove it from the Bill window. If you make a mistake or need to rewrite a heading, simply delete an item and add it again.

Click “Save” or “Save + Exit”

Click the Save button to save your work, or Save + Exit to save and close the Billing Configuration tool.

Add Default ICD-10 Diagnosis Codes to the Bill Window (Electronic Encounter Form)

You can also additional ICD-10 codes to your Electronic Encounter Form. These codes will appear, ready for selection, whenever you click “Bill” from a chart note.


Diagnoses should always be recorded on the chart note, accompanying other assessment notes. However, there are a few unusual billing situations where you may need to add an ICD-10 billing code to an encounter.

For example:

  • Some PCMH programs ask for BMI percentile coding on claims. There are ICD-10 codes for BMI percentiles that are not described by SNOMED-CT. Your practice could add the BMI percentiles to the electronic encounter form for easy selection during any visit.
  • The ICD-10 codes for abnormal well visits do not have a set of clear 1-to-1 associations in SNOMED-CT.

You can use the Billing Configuration tool to add ICD-10 diagnoses to your billing screen.


As you add diagnosis codes, remember that these codes are for billing purposes only. They will not appear on the patient’s chart note or be part of a patient’s medical history or summary of care.

Example: Configure Immunization Orders to Trigger a Diagnosis and Billing Procedure Code

Use the Billing Configuration tool to configure each immunization order so that it triggers the appropriate billing codes for both the diagnosis and the procedure. The standard PCC installation includes this configuration, and PCC Support will be happy to help you adjust your configuration.

Your practice can use the Billing Configuration tool to configure your immunization orders.

Open each order and adjust billing diagnoses and procedures.



If you add the Z23 “Encounter for immunization” billing diagnosis code to all immunizations, and add the appropriate billing procedure codes as well, it will save time later for your billers.

You can also add additional, unselected codes to orders (as shown above) in order to make them available on the electronic encounter form whenever an order is placed.

Configure the Order in Which Medical Procedures Appear on a Claim

While it is not part of the claim standard, some payers have rejected vaccine procedures if they appear on a claim before the well visit code. You may encounter other situations where a payer’s claim software denies procedures based on their order.

If a payer suggests you need to rearrange how procedures appear on claims (for example, to have the well visit code appear before immunization codes), you can reply to the payer that they are not following the claim standard and should pay the claim as-is.

However, PCC can also adjust your configuration to have certain procedure codes always appear first on a claim.

First, identify all of your visit codes and the payers who have asked for this non-standard configuration. If possible, obtain documentation for the corresponding requirement(s). Contact PCC Support and ask them to add these codes to the claim generation configuration file for the insurance batches for the indicated payers. PCC Support will add your list of codes to the procedure order question for the relevant insurance batch. (Under-the-hood, this question reads: “In what order should procedures appear on the claim form; list procedure codes in order by priority:”) Then, when you process claims for that payer, those codes will appear first.

Edit Your Practice’s Prices and Billing Procedure Codes

When you need to add a new CPT code to your PCC system, or adjust your prices, use the Tables tool found in the Configuration menu to edit your Procedures table.

Read the Steps: You can read a guide to learn how to add or update procedure billing codes, prices, and other procedure information.

Watch a Video: Watch Edit Your Prices and Billing Procedure Codes for a video tutorial of the steps.

Add an Immunization: You can also read a more specific guide, which covers additional details and steps for immunizations: Add and Configure Immunizations.

Submit Immunization Records to CAIR

August 3, 2015/in Configure Other PCC EHR Features Configure PCC EHR /by Douglas Beagley

If your practice is located in California, you can use PCC software to submit your patients’ immunization records to CAIR, the California Immunization Registry.

You can also look up and import immunization records from CAIR without ever leaving PCC EHR.

Follow the steps below to begin submitting.

Turn On Immunization Registry Communication Preferences

CAIR requires that you record immunization communication preferences for each patient. You can turn on the Immunization Communication Preference fields in the Contact Information component in the Protocol Configuration editor.


For Every Patient, Fill Out Immunization Registry Preferences

Train your staff to review and fill out the Immunization Communication Preference for each patient.

For each patient, permission to share must be set to “Yes” or “No”.

The “Immunization Registry Communication Preferences” appear in the Patient Contact component, which appears by default in the Demographics section of the patient’s chart.

Your practice could also use the Protocol Configuration tool to add the Patient Contact component to a chart note, the standard phone note, or the Medical Summary.

Preferred Contact Method: CAIR requires the “Share with Registry” answer for all patients, to determine if their records may be shared with the registry. CAIR’s specifications state that the secondary “Preferred Contact Method” field must be sent to the registry if it is collected, but the field may be empty. From past experience with immunization registries, PCC recommends that you fill this field with the patient or family’s contact preferences for information related to immunization registries. For example, if the family does not wish to be contacted, select “No Reminders and No Recalls”.

For Every Patient, Fill Out VFC Information During Each Visit

CAIR requires that you state whether or not a patient was eligible for VFC for every shot administered. PCC EHR can’t determine that for you, but it can provide your clinicians with all the information they need to determine eligibility and display a tool for assigning it quickly.

Train your staff to review the information and select VFC eligibility status during each visit.

Last Answer: At the patient’s next visit, PCC EHR will remember the patient’s previous VFC eligibility status. They can click “Last Answer” to enter it for all immunization orders.

For Every Patient, Collect Race and Ethnicity

CAIR requires race and ethnicity information for every submission.

Train your staff to review and update race and ethnicity information during each visit. They can enter it during patient checkin.

Talk to PCC Support to Set Up Your Connection to the CAIR Registry

Contact PCC Support at 1-800-722-1082 or support@pcc.com.

We will set up the electronic interface between your practice and CAIR.

Indicate If You Want A Bidirectional Interface: When you contact PCC Support about getting connected to CAIR, indicate if you would like to be able to both submit and retrieve immunizations from the registry.

Contact CAIR to Get Your CAIR Site ID and Register Your Vendor

PCC will need your CAIR site identification number to complete your configuration. You may need to assign PCC as your vendor, particularly if you submitted to CAIR with a previous vendor.

To obtain or reassign your site identification number, contact CAIR at your regional CAIR office. You can find a list at http://cairweb.org/dataexchange-contacts/.

Learn More at cairweb.org: The CAIR web site has additional information. Feel free to contact PCC Support for help getting started or implementing any of the steps above.

Configure Co-Signing

August 3, 2015/in Configure Other PCC EHR Features Configure PCC EHR /by Douglas Beagley

If your practice needs some visits signed and co-signed, you can turn on co-signing and then require it for specific users.

First turn on Co-Signing in the Practice Preferences tool, found in the Configuration menu.


Next, open the User Administration tool and visit the “Roles” tab.


Either edit an existing role, such as a group that always requires co-signing, or create a new role (as pictured above) specifically for the co-signing requirement.

When you edit the role, select the “Signing” and “Co-Signing” options.

Next, edit the account for each provider’s that requires co-signing, and add the appropriate role to their Role Assignment tab.


Permissions: Access to the Practice Preferences and the User Administration Tool are controlled through the PCC EHR User Administration Tool. Contact your office’s PCC EHR administrator or PCC Support if you need help.

PCC EHR Configuration Introduction

August 3, 2015/in Get Started Configure Other PCC EHR Features Configure PCC EHR /by Douglas Beagley

You can configure PCC EHR to match your workflow and charting style. You can change how many screens behave in order to help your office find what they need quickly. The help articles below include procedures and references to make changes to PCC EHR’s behavior.

PCC Support can help you with any of the tools below. Before you make major changes, feel free to call us and chat about them. When you go online with PCC EHR, you design chart notes and make a lot of choices, and it is important to revisit and adjust that configuration as your office grows more comfortable with the many tools and features in PCC EHR.

Contact PCC Support at 802-846-8177 or 800-722-7708 or support@pcc.com for further assistance.

Configure the Schedule Screen

August 3, 2015/in Configure Other PCC EHR Features Configure PCC EHR /by Douglas Beagley

You can turn on and off some of the columns on the Schedule screen.

First, open the Practice Preferences window from the Tools menu.


Next, select which columns you wish to display.

Log out and back in again to view your new Schedule screen. Your changes will take place for each user, the next time they log in.

Permissions: Access to the Practice Preferences and the User Administration Tool are controlled through the PCC EHR User Administration Tool. Contact your office’s PCC EHR administrator or PCC Support if you need help.

Configure Lab Orders and Lab Tests in PCC EHR

August 3, 2015/in Configure Other PCC EHR Features Configure PCC EHR /by Douglas Beagley

Your clinicians can click “Order” next to a lab order on a chart note in PCC EHR and automatically queue up tests, tasks and more. PCC EHR’s lab orders can contain several result fields, default facilities, and initiate tasks for the tasks queue. Your common labs can automatically appear for selection on appropriate chart notes.

Read the sections below to learn how to configure lab orders in PCC EHR.

Video: Lab Configuration Overview: You can watch a video that introduces lab orders in PCC EHR and shows you the procedures described in this article. CLICK HERE

Video: Electronic Lab Order Configuration: Watch a video that shows you how to configure electronic lab orders in PCC EHR. CLICK HERE

Run the Lab Configuration Tool and Review Your Labs

Use the Lab Configuration tool to add tests to existing labs, create labs and snap labs from scratch, manage your office’s list of lab facilities, and modify other configuration settings.

Run the Lab Configuration Tool from the Configuration menu.


Your lab orders appear in the first tab, along with columns that indicate if they are a snap lab, the default lab facility, checkboxes that indicate default settings for the lab, whether or not the lab has any configured LOINC tests for result entry, and whether or not the lab order is configured for an electronic results interface with a third party vendor, such as Quest or LabCorp.

Permissions: Your practice can configure which PCC EHR user roles have access to the Lab Configuration tool. Use the User Administration tool to adjust the permissions for any role. If you can not access the tool, ask your office’s PCC EHR System Administrator to grant you access. You can also call PCC Support for help.

You can select a lab order and scroll to the right to see additional summary information.

Optionally, you can click on the disclosure arrow to see the specific configured tests for the lab.

A lab order may have one or more tests configured for manual entry, as well as one or more third-party vendor tests configured for results that will be sent to PCC EHR electronically.

E-Lab and Non-E-Lab Orders in PCC EHR

You can create any kind of lab order in PCC EHR, and optionally base it on standardized LOINC lab tests or a free-form result field. When you receive results, you can enter them manually in the result fields for the order.

PCC EHR can also receive lab results electronically from hospitals and third-party vendors, such as Quest or LabCorp. When you receive lab results electronically, they arrive on a special e-labs queue.

Contact PCC Support to get started with e-labs. We’ll help you figure out how to contact e-lab vendors, how to configure lab orders for electronic results, and how to adjust your practice’s workflow to review incoming lab results.

  • Read the “Create or Edit a Lab Order” section below to learn how to link an e-lab vendor’s lab tests to a lab order in PCC EHR.
  • Read Import E-lab Test Results to see the e-lab results workflow in action.

Create or Edit a Lab Order

Use the first tab of the Lab Configuration tool to create or edit labs, adding test and result fields. You can also set default lab facilities, order settings, expected ranges, and interpretation requirements.

Select an Existing Lab or Create a New One

First, double-click on a lab order to edit it. (Or, click “Add Lab Order” to start from scratch.)


Edit Lab Order Name and Default Facility

Next, review and update the lab order name and set the “Default Lab Facility”.


In-Office Labs: For in-house labs, set the default facility to be your in-office lab. If you have multiple locations with their own in-house labs, set the default facility to “Use Appointment Location”. “Use Appointment Location” only works if your lab facilities are mapped to scheduling locations. Facilities and scheduling locations are managed on the Lab Facilities tab.

E-labs Options: If your practice is configured to receive lab results electronically from a hospital or third-party vendor, you may elect to have separate lab orders for these “e-labs”. In that case, you may create multiple labs for each vendor, or create a single lab order. You can use the lab order name and default facility to speed up your workflow when creating these lab orders.

Configure Specimen Collection, Default Privacy Behavior, and Refusal and Contraindication Options

Next, review and edit the settings and default behaviors for this lab order.

  • Specimen Collection: If you wish to record specimen collection information for this lab order, click “Enable recording of Specimen Collection user, date, and time”.

  • Appear on Patient Reports and My Kid's Chart: If you wish this lab to be visible by default on patient reports, including the Patient Visit Summary and My Kid’s Chart (the patient portal), select “‘Include on Patient Reports’ will be selected when this order is issued”. Clinicians can determine whether or not a lab order is visible at any time for any order by selecting the check box on the specific order for a patient.

  • Refusal and Contraindication: If a lab order can be refused or contraindicated, select the appropriate options to enable those checkboxes on the order.

Privacy and Lab Orders: If you want every lab order of this type to be automatically hidden from all PCC EHR output that goes to a patient or family, deselect the “Include on Patient Reports…” option on this screen. Your practice may choose to do this for all lab orders, if you would like to review results before making a lab available to families. Your practice may also choose to do this for labs of a sensitive nature. Clinicians can also choose to make the specific instance of a lab order visible on reports and in My Kid’s Chart on a case-by-case basis.

Add SNOMED-CT Terminology for Meaningful Use or PCMH Reporting

If your practice is applying for the ARRA EHR Medicaid Incentive Program, seeking PCMH recognition, or applying for some other incentive or results based program, you may need to add SNOMED-CT procedure codes to a lab order in order to track usage for specific labs.


You can see examples of this in action on the How to Chart for Each Clinical Quality Measure in PCC EHR article.

Add Lab Tests for Third-Party Vendors

Next, if your practice receives results for this lab order electronically from a hospital or third-party vendor, you can add their specific lab test to this lab order.

Use the Vendor's Lab Order Code: How can you be sure to match up your lab order with your hospital or third-party vendor’s labs? Use the lab order code, found either on the lab requisition form or on the vendor’s web site. You can type the lab order code into this field to search for and select it. Each lab vendor has a unique list of lab order codes, and some vendors may create unique code numbers for your practice. If you can’t find the order code you need, you can also contact your vendor representative.

When you link your lab order to a third-party vendor’s unique lab test, PCC EHR will be able to correctly associate and track the lab results with the order in the patient’s record. For more information about e-labs, read the Import E-lab Test Results article.

Add Lab Tests for Manual Result Entry

Next, add, remove, or edit tests to your lab order. (If you will receive all results for this lab order electronically, you can skip this step.)

You may add multiple test results to store discrete values. For example, for a urinalysis lab, you might measure pH, protein, bilirubin, nitrate, specific gravity, or other values.


Type a name or code for a test in the field at the bottom to perform an instant search and add a test to the lab order.

LOINC Codes and Choosing the Right Tests: All tests are based on LOINC codes, the industry-wide lab test standard. You can type a LOINC code into the search box to ensure you get the correct test. PCC Support can work with you to set up lab orders, so be sure and call us for consultation as you create your labs.

Enter Normal Reference Ranges and/or Interpretation Requirements

For each test, you can indicate a reference range or normal result range, and choose whether or not someone at your office must select an Interpretation for the lab to be complete.

Click “Save”

Click Save to save your lab order changes.

Optional: Add Labs to Protocols

You can order any lab from the Labs component, which is probably on your chart note protocols already.

You can also add specific labs to specific chart notes. Use the PCC EHR Configuration Tool to add common labs to your chart note protocols. Contact PCC Support for assistance.

Configure Billing

When you order a lab on the chart note, PCC EHR can automatically select the appropriate procedure code or codes on the electronic encounter form. Read the Billing Configuration article to learn how to link labs (and other orders and procedures) to specific procedure codes and optional billing codes.

Repeat the above procedure to configure all your lab orders.

Create or Edit a “Snap Lab”

A Snap Lab is a one-click lab that orders several labs.

When a patient complains of pelvic pain, you might want to order a urinalysis, a UPT, and a PAP. You can use the Lab Configuration tool to create a Genitourinary Snap Lab. Doctors can then order all three labs with a single click.


Follow the procedure below to create Snap Labs that will make ordering several labs at once quick and easy for your physicians.

Click “Add Snap Lab Order”

Click “Add Snap Lab Order” on the Lab Orders tab of the Lab Configuration tool.

Enter a Name

Enter an easy-to-remember name for your Snap Lab.

Add Labs

Type lab order names in the bottom field to search for labs. Select them or press Enter to add them to the Snap Lab.

Click “Save”

Optional: Add Your Snap Lab to a Chartnote Protocol

You can add your Snap Lab, or any regular lab, to your chart note protocols. For example, if you have three labs you typically perform during a well visit, they could be a snap lab that was preconfigured to appear on well visit chart notes.

Manage Your List of Lab Facilities

Click on the “Lab Facilities” tab of the Lab Configuration tool to review your office’s lab facilities.

Click “Add” to create a new facility, or select a facility and click “Delete” or “Edit”.

What facilities should be on your list?

  • Your Office(s): PCC recommends you create a lab facility entry for each of your in-house labs. Use your practice (or practice location) name and address, and check the “In-Office” box to indicate it is an in-house laboratory.

  • Your Hospitals and Other Lab Services: Add any hospital or other outpatient lab facility to which you refer patients.

Complete Addresses: When adding a facility, always include the complete address of the lab location. In addition to better record-keeping, future lab reports will include the complete facility address, which is a requirement of CLIA and ARRA.

Map Scheduling Locations to In-Office Lab Facilities: If your office schedules appointments in more than one location, click the “Location Mapping” button to tell PCC EHR which lab is at each location.


Use the pull-down menus to indicate which in-office lab facility corresponds to each of your practice’s scheduling locations. These mappings are referenced by in-house lab orders configured with the “Use Appointment Location” option.

Manage Your Practice’s Sublist of Common Lab Tests

PCC EHR includes 60,000 tests for use in your lab orders. Since constantly selecting from a list of 60,000 tests is undesirable, your office can configure their own subset of common lab tests in the Lab Configuration tool. PCC has begun this process for you, marking 2000 tests as “Commonly Used”.

Click on the “Common Tests” tab to review and revise your office’s sub-list.

PCC has selected a subset of common tests for you, as indicated in green and with the check box for “Commonly Used”. If you do not find a test you need while configuring your labs on the Lab Orders screen, use this tab to edit the list of available tests.

Provider Defaults for a Lab

PCC EHR remembers each provider’s preferred behavior for each lab order.

The first time a user orders a newly configured lab in PCC EHR, they might set an assigned user and create a task. They might also enter results and other notes in the correct fields. PCC EHR remembers all of this information.

The next time the same user orders the same lab, the assigned user and preferred task will appear automatically. When they begin to type results or notes, PCC EHR will offer their most recent entries for easy selection.

Remove Defaults: If your provider wishes to change (or remove) the default assigned user for a lab, or wishes to remove the default task that appears whenever they order a lab, they can simply blank out those fields and save their changes.

Confidential Lab Default: You can use the Lab Configuration tool to set whether or not a new lab order will be visible on reports and the Patient Portal by default. See above for details.

Add Specific Labs to Chart Note Protocols

Most chart note protocols include the “Lab” component, with a blank entry field. Any user can then order a lab simply by using the search field and selecting the correct lab.

For ease-of-use and visit order consistency, you may choose to add specific labs to your chart notes. Read the Protocol Configuration Tool guide to learn more about adjusting your chart note protocols.

Create Clinical Alerts, Patient Lists or Patient Reminders Based on Lab Results

Clinical Alerts pop up on the screen when patients meet certain criteria. Patient Lists and Patient Reminders can find all patients who meet certain criteria. You can use any lab test that you have charted in your office as a criteria for Clinical Alerts, Patient Lists, or Patient Reminders.

Follow these steps to create an alert (or list or reminder) based on lab test results.

Enter Lab Results

You can’t make a report or an alert about a lab test that has never occurred in your practice. Order a lab and enter a result first. If you are trying to set up a series of alerts ahead of time, use a test patient.

Create Your Alert or Report

You can read a detailed guide, including screenshots, for help creating Clinical Alerts, Patient Lists, and Patient Reminders.

Fill Out Criteria

Give your report or alert an appropriate name, and then use the Lab Order section of the criteria to add the lab test.

Professional Contact Manager

August 3, 2015/in Configure Other PCC EHR Features Configure PCC EHR /by Douglas Beagley

Use the Professional Contact Manager to manage the list of your practice’s professional contacts, school medical personnel, and other professionals who may be part of care plans for many different patients.

When you add team members to an intervention in a patient’s care plan, you can select from your practice’s list of professional contacts.

Click on the Tools menu and select Professional Contacts to open the tool.


You can search through the list, sort by different columns, or click Add, Delete, or Edit to make changes.


After adding a professional contact, you can select them as a team member for an intervention in a patient’s care plan.

Direct Address: You can manually enter a Direct Address, or search in the field. You will see more results if a user at your practice is registered with the DirectTrust network.

Permissions: Access to the Professional Contact Manager is controlled through the PCC EHR User Administration Tool. Contact your office’s PCC EHR administrator or PCC Support if you need help.

Review and Edit Sibling Charts

August 3, 2015/in Chart a Visit Chart a Visit /by Douglas Beagley

You can open several sibling charts and work on them at the same time, flipping back and forth between them as needed.

Open a Chart

Begin by opening a patient’s chart, either by double-clicking on the Schedule screen or using the Find field.

Find the Siblings Component

Next, locate the Siblings component on the Medical Summary screen.

Can't Find Siblings?: If your practice has removed the Siblings component from your Medical Summary screen, you can still find it on the Demographics screen.

Open a Sibling Chart

Click “Open Chart” next to any sibling to open their chart side-by-side with the current chart.

You can open up to four sibling charts at once.

Switch Back and Forth Between Charts

While you have multiple sibling charts open, you can click on the tabs at the top of the screen to flip between them.

Chart a Visit, Create a Phone Note, Make a Prescription:

You can treat each tab just as you would any open chart. You can mark a sibling as arrived, or create a visit, and then chart both patients at the same time. You can visit the Prescriptions screen, create labs and orders, or take a phone note and create follow-up phone tasks for either patient.

Save Your Work and Close Charts

If a chart has unsaved changes, an asterisk will appear by the patient’s name. Click on the close button on the tab to close a chart. You will be warned if you have any unsaved changes.

Chart Note Protocols

August 3, 2015/in Chart a Visit Chart a Visit /by Douglas Beagley

Chart notes are made up of different sections, or elements, that a particular visit type needs. The custom chart note is called a protocol. You will see a different protocol for different visit reasons, and providers may have their own, custom protocols.

For example, if you chart a sick visit, you will see buttons and sections for History of Present Illness, Review of Systems, and Plan Notes. If you are charting a Well Baby Physical, the chart note template may include Physical Exam notes and Immunizations.

Patient Vitals, along with tools for requesting Prescriptions and Labs, are all contained within the chart note. A template may include other sections of the patient’s chart, such as their Immunization History or the patient’s Medication List, so that the provider can easily review important information during a visit. When a lab or procedure is ordered, it is automatically added as a new element at the bottom of the chart note.

Protocols are Customizable

PCC Software Support can help you customize your chart note protocols, building new custom chart notes for your workflow. Your practice may wish to use custom protocols for each visit type, for each provider. You can select exactly which elements, from a customizable list, appear in the chart note for each protocol.

To learn more, read the Protocol Builder help articles.

Bright Futures: The Bright Futures protocols are available in PCC EHR, providing your office with a set of pre-made workflow chart notes designed by pediatric specialists. You can start with the Bright Futures protocols and then use the PCC EHR Protocol Builder to make adjustments to suit your needs.

Add or Switch Protocols During a Visit

You may perform a Well Child appointment that turns into a Sick Visit appointment. You can grab any chart note protocol and use it in addition to, or instead of, the visit for which the patient is scheduled.

Watch a Video: Watch the Working with Multiple Protocols video to learn how to add, remove, or change chart note protocols during a visit.

Add and Work with Two or More Protocols

Follow the procedure below to add a chart note protocol to a visit.

Open a Chart and Begin Charting

Double-click on a patient to open their chart.

When You Require a Different Protocol, Click Edit–>Add Protocol

Select a New Protocol from the Pull Down List

Begin typing and then click on the desired protocol to select it.

Continue Charting Using Either Chart Note

The new protocol will appear on a tab at the top of the screen. You can select either tab and jump back and forth between them as needed.

Note: In the patient’s Visit History, the two chart notes will appear together, listed as one visit.

Switch Chart Note Protocols

Follow the procedure below to switch a visit to a different chart note protocol, automatically moving over any charted data.

Open a Chart and Begin Charting

Double-click on a patient to open their chart.

When You Require a Different Protocol, Click Edit–>Change Protocol

Select a New Protocol from the Pull Down List

Continue Charting Using the New Chart Note

Note: Any information you entered into the first, original chart note will be brought over into the new chart note. Later, in the patient’s Visit History, PCC EHR will display completed items that were not in the second chart note at the top of the visit’s entry.

Remove a Chart Note Protocol

Follow the procedure below to remove a chart note protocol that is unneeded or was added in error.

Click Edit–> Remove Protocol

Select a Protocol and click “Remove”

If Removing One of Three or More, Indicate Where Charted Data Should Be Move

If you are charting a visit with three or more protocols, PCC EHR will ask you where to move charted data from the protocol you are removing.

Review Activity, Continue Charting

PCC will confirm that charted information will be moved, and you can continue charting.


In the example above, a chief complaint from the Asthma protocol was added to the Chief Complaint section of the Sick protocol. If no equivalent component is available, charted information will be added to the top of remaining chart note protocol.

Chart a Visit in PCC EHR

August 3, 2015/in Get Started Chart a Visit Chart a Visit /by Douglas Beagley

Read the procedure below to learn about each step of a typical visit in PCC EHR.

Watch a Video: Want to watch a 5-Minute Charting video? CLICK HERE.

In order to introduce you to many PCC EHR features, this is a long and detailed procedure, with many optional steps. You can learn more at https://learn.pcc.com/PCCEHR. Contact PCC Sales for a complete demonstration, or call PCC Support for help with any feature.

Open PCC EHR and Log In

Double-click on the PCC EHR icon and enter your username and password.

Open a Patient Chart

Find a patient on your schedule and double-click on the patient name. Or select them and click “Open Chart”.

Optionally, Find Any Patient: Instead of selecting a patient from the Schedule, you could enter a name, birth date, or PCC number in the Find search field.

Optional: Review Patient Chart

You can use the chart navigation buttons to review the Medical Summary.

You can also review other parts of the patient’s chart, like their growth charts or immunizations record.

Start Visit

Click on today’s chart note navigation buttons to begin charting the visit.



Patient Management: If the patient was not already checked in, you can click “Arrive Patient” to gain full access to all charting tools. If the patient has no scheduled visit for today, you can create a walk-in visit. Finally, you can control patient visit status at the top of the chart note.

Optional: Pre-Collect Vitals or Other Patient Prep Information

On a typical chart note, the first set of items relate to intake. A nurse or other clinician may collect the vitals, record them in the chart note, and then save and close the chart.

As you enter vitals, PCC EHR’s customizable components can give you feedback, such as BMI and growth percentile for the patient.

Review Who Entered Vitals: Move your mouse cursor over vitals on a chart note to see who entered the data.

Hover over any vitals measurement (not entered by yourself) to reveal attribution.

Change the Clinician?: If you need to change the assigned clinician for an encounter, you can double-click on the chart note to open it and change the provider field at the top of the screen.

Optional: Review Problem List and Other Chart-Wide Information

The Problem List and other chart-wide components may also appear on your chart note. You can review the information and click “Edit” to make changes.

Record That You Reviewed The Information: For the Problem List, Allergies list, and generic chart-wide text components, you can click “Mark as Reviewed” to document that you reviewed the information.

When you click “Mark as Reviewed”, the contents of a component as it appears on the screen will be saved as part of the encounter. You can later review it in the Visit History.

Examine Patient, Enter Chart Notes

Click on any of the chart note navigation buttons to jump to sections of the chart note. You may also use the scroll bar or the “Next ” and “Previous” buttons to move down through the chart. Chart notes consist of components that provide patient information or provide tools for taking notes, creating orders, or other charting needs.

Answer Memory, Last Saved Answer, Configurable Defaults, and Auto-Notes Help You Chart: PCC EHR remembers your common notes and can help you speed up charting. You can configure your practice defaults for many fields, such as blood pressure and temperature method. Many fields can provide a pull-down menu of previous responses and/or display the patient’s last saved answer.

PCC EHR’s Auto-Notes can store and enter your notes quickly for you, based on your selection. Learn more in the Auto-Notes help article.


Optional: Add Photo or File Using Your Mobile Device

You can use pocketPCC on your phone or mobile device to add a photo to the chart note.


Enter Diagnoses, Update Patient’s Problem List

In the Diagnoses section of a chart note, select or enter diagnoses.

If a diagnosis should be added to the patient’s Problem List or Allergies list, you can do so while charting, as shown below. If a diagnosis is already on the patient’s Problem List, it will be listed first in the drop-down of available diagnoses.

If an item is already on the patient’s Problem List or Allergies list, PCC EHR will indicate that.

The Problem List and Allergies list appear on the Medical Summary.

Unusual Diagnosis?: If you can not find a diagnosis by typing, you can right-click to search the entire SNOMED-CT diagnosis list by description or by associated ICD-10 billing code.


Optional: Order a Lab, Immunization, Medical Procedure, or Other Order

Click “Order” next to a lab or other order to create it.

Use the blank entry to find and create an order that is not a default on the chart note.

After you click Order, you can click “Edit” and enter notes or modify the tasks that go along with that order (if any). The order’s tasks will appear on the Visit Tasks queue.

PCC EHR remembers how each provider likes each order performed and offers the last task and other settings you used. The notes fields and other order-related details all remember your common entries for easy selection.

Optional: Enter a Prescription or a Refill

Click on the “PCC eRx” button and use PCC EHR’s integrated prescribing tools to review and update medication history or create a prescription for the patient. You can do this at any time and then return to charting.


Optional: Fulfill Labs, Procedures, or Other Orders

Whenever you order a lab, medical procedure, or other order, your office will see an orange ball indicator on the schedule screen. They can also track orders on the Visit Task queue, and the navigation button for that order is highlighted.

You can grab an order from the chart note (by clicking “Edit”), click the orange ball on the Schedule screen, or find it on the Visit Tasks queue. Then you can complete the order’s tasks, enter results, make notes, or create additional tasks.

Optional: Generate a Visit Summary Report

You can generate a handy end-of-visit report for the patient and family. Click “Print Visit Summary”, or select the Patient Visit Summary report from the Reports menu.


The Visit Summary includes everything that happened today, along with an immunization record and other key patient information.

Optional: Click “Bill Visit” and Make Diagnoses and Procedures Ready For Billing

Click on the “Bill” button at the bottom of the screen to review diagnoses and procedures and select additional items on PCC EHR’s electronic encounter form.


In the Bill window, you can review charted diagnoses and procedures, add the visit code, and link diagnoses and procedures. For a complete guide, read Send an Encounter to Billing in PCC EHR.

Save Changes, and/or Sign the Visit

At any time during your work on the chart note, click “Save” to save your changes. If you do not click Save, PCC EHR will remind you to save when you close the chart or return to the schedule.

Sign Off On a Visit: You can click the “Sign” button in the lower right-hand corner to sign (and then close) a chart. Unsigned visits, and any orders or documents requiring a signature, also appear together in a list on the Signing queue.

What Happens Next?

After the clinician has charted the exam, selected diagnoses and procedures, confirmed the items on the electronic encounter form, and signed the chart, they are finished.

Other clinicians, the front desk, or other staff at the practice might still need to complete orders for the patient, including scheduling followups, creating referrals and more.

The checkout or billing staff will post charges and queue up a claim. To learn how they do that, read Post Charges and Check Out Patients in PCC EHR.

Delete an Encounter from a Patient’s Chart

August 3, 2015/in Chart a Visit Chart a Visit /by Douglas Beagley

You can delete a visit created in error in PCC EHR. When you delete a visit, all vitals, chart notes, orders, and other items created for the visit are removed from the patient’s record.

When Do You Need this Feature?

When a patient does not show for a visit, and nothing is done on the chart note, you can cancel or mark the appointment as missed to remove the chart note.

Under some circumstances, however, you may also need to delete a chart note with notes, so the visit does not show in a patient’s chart.

For example, a user may have entered notes for the wrong patient, or a chart note may have been opened and edited ahead of time, before the visit, and then the visit was canceled. Finally, your office may have accidentally schedule a patient twice, creating a duplicate record.

Step One: Chart the Visit for the Correct Patient

If you scheduled and charted an encounter on the wrong patient’s record, you should begin by creating an appointment, charting, and billing for the encounter for the correct patient.

Step Two: Cancel, Delete, or Mark the Appointment as Missed

To delete a chart note, you must first cancel, delete, or mark the appointment as missed. You can do so in the Appointment History component (usually found on the Medical Summary in the chart), or right on the Appointment Book.

If the chart note was never arrived or edited, then just by removing the appointment you will remove the chart note.

Step Three: Delete the Visit Chart Note

After you delete the appointment, if the encounter still remains in the Visit History, run the Delete Charted Visit tool in the Tools menu. Only users with access permissions can open this tool.


Select from the list of appointments, and double-check the chart note details at the bottom of the screen. You can use the “Find by” menu to search for the chart note by date or other details.

When you are certain you have found the chart note you need to delete, click “Delete”.

Items Attached to the Chart Note: If you attached a document to a chart note, and then the chart note is deleted, the document will remain available in the Documents section of the patient’s chart. You can return any document to the Import Documents source folder by using the Edit button in the Documents section of the patient’s chart. If the visit had any imported e-lab results, the e-lab results file will return to the Import E-Labs queue.

Permission Settings: Since deleting a chart note is a significant action, PCC recommends your practice keeps the feature turned off for all user roles. When you need it, your practice’s system administrator can add Delete Chart Visit permissions to a user role with the User Administration tool.

Step 4: Delete Posted Charges, Void the Claim, and Take Other Billing Actions

If your practice posted charges for the encounter, you should delete the charges and billing history from the patient’s billing account. If you have submitted a claim on behalf of the wrong patient, you may need to contact the payor and void the claim.

When you make changes to the billing account, consider adding an account note to the record, explaining what happened.

Search the Patient Visit History or within a Charted Encounter

August 3, 2015/in Chart a Visit Chart a Visit /by Douglas Beagley

You can quickly find a visit by searching a patient’s complete history, then use the find feature to jump directly to the keyword you’re looking for within the visit or note.

Search the Patient Visit History

From the Patient Visit History, enter a phrase or keyword in the search box – a diagnosis, order, or other visit detail, and click search or press enter.

The Visit History Index will change to display only the visits that contain the search term you entered. The search box will show a count of how many visits contain that term, and which of those search results you currently have selected.

When you select a visit, the count will change to indicate which of the resulting visits you’ve selected. In the visit history window above, each instance of your search term will be highlighted.

To return to the full list of visits, click the x in the search box to clear the search.

Search within a Charted Encounter

With a note or a visit open, you can select Find from the Edit menu to search through a visit chart note, the medical summary, or another protocol-based chart section. You can also use your operating system’s keyboard shortcuts (ctrl+F on Windows or Linux, command+F on Macintosh).



PCC EHR will search the visible text in the ribbon. You will see the total found results, and the first result will be highlighted for you.

You can click the arrow buttons to cycle through matching results, or press the keyboard shortcut (F3 on Windows, command+G on Mac OSX, and ctrl+G on most Linux installations) to move to the next result.


You can use the new search feature to find a lab result, jump to a note about a specific problem or diagnosis, or find anything else that appears in visit chart notes, phone notes, or the Demographics or Medical Summary chart sections.

Search Through "Visible" Text: The find feature does not search through text that is not visible in the ribbon. For example, if the expand arrow on a Care Plan intervention is closed, you will only be able to find visible portions of the intervention.

Spell Check in PCC EHR

August 3, 2015/in Chart a Visit Chart a Visit /by Douglas Beagley

PCC EHR automatically checks your spelling as you type.

Whether entering chart notes, writing up the patient’s care plan, or entering text in any other free-text field, PCC EHR will underline misspelled words.

Spell check automatically ignores name fields, phone number fields, and other fields where spell check would be undesirable.

Suggestions

Right-click on an underlined word to see spelling suggestions.

You can select the correctly spelled word from the menu, and it will automatically replace your typed text.

Medical Dictionary Included

The PCC EHR spell check includes a medical dictionary and words from SNOMED descriptions. Your every-day medical terms will be interpreted correctly, and the suggestions will reference common medical terms as well.

The PCC EHR dictionary is a custom combination of the open-source Hunspell English Dictionary, the OpenMedSpel dictionary, and a parsed list of SNOMED descriptions.

Add Words to Your Spell Check Dictionary

Even with the medical terms and SNOMED descriptions, you will undoubtedly encounter unknown terms that are spelled correctly. When a word is spelled correctly, you can right-click to add it to your personal spell-check dictionary.

In the above example, the user decided that they want the word “meds” to be considered correct.

Per-User: Custom words added to the spelling dictionary are for each user, not for your entire practice.

Remove Custom Words: You can also remove items that you add to your dictionary in error. Simply right-click on the word and select “Remove From Dictionary” from the pull-down menu.

Find and Refine Diagnoses as You Chart

August 3, 2015/in Chart a Visit Chart a Visit /by Douglas Beagley

As you work on a chart note, you can enter diagnoses in the Diagnoses component.

Find Diagnoses

When you search for diagnoses, PCC EHR searches independently of the order of your terms, and will allow searches of partial words.

Active Problems: If a patient has any active problems on their Problem List, these will appear at the top of the diagnosis drop-down, so you can find them quickly.

If you can’t find a diagnosis by typing, you can right-click to search the entire SNOMED-CT diagnosis list.


Find Diagnoses by ICD-10 Code

If you prefer to document diagnoses by billing code, you can search and find all mapped ICD-10 codes.

Right-click on the Diagnosis field and select “Find Other Diagnosis”.

Enter the ICD-10 code you need. As you type, a list of SNOMED-CT diagnosis descriptions with mapped ICD-10 codes matching your request will appear.

Not Finding the ICD-10 Code You Need?: If you search for a diagnosis by its ICD-10 code and can’t find it, it’s probably not mapped to a SNOMED diagnosis code. You can adjust the billing code mapping for any diagnosis in the Billing Configuration tool. Once you’ve mapped the ICD-10 code, you’ll be able to find it any time you do an advanced diagnosis search.

Add a Charted Diagnosis to a Patient’s Problem List

Use the Problem List features in the Diagnoses component to add a charted diagnosis to a patient’s Problem List.

If an item is already on the patient’s Problem List or Allergies list, PCC EHR will indicate that.

Refine Diagnoses

PCC EHR can help clinicians select a more specific diagnosis description. After they select a diagnosis, they can use a drop-down menu to refine the selection.

The Refine Diagnosis drop-down menu will show the hierarchy of related SNOMED diagnosis descriptions. The clinician can quickly pick a more specific description.

After selecting a more specific description, it will replace the existing diagnosis. If there are even more specific options, the clinician can make another selection.

By refining diagnoses, clinicians can chart with greater specificity and accuracy. Greater specificity, where appropriate, also improves mapping to ICD-10 codes, which can result in more paid claims.

Optional: The Refine Diagnosis drop-down menu is an optional tool that allows you to quickly select similar diagnoses that are below the selected one in the hierarchy of SNOMED diagnosis descriptions. You can use it to explore more specific diagnosis descriptions, but in some cases the more specific code is unnecessary or not appropriate for a visit.

Review and Adjust ICD-10 Billing Codes for a Charted Diagnosis

When a physician selects a diagnosis, PCC EHR automatically presents the ICD-10 billing code. If additional information is needed for ICD-10 billing, the chart note will ask the physician the relevant questions.

For example, if a physician diagnoses “Failure to Thrive” for a child, PCC EHR will automatically identify R62.51 as the ICD-10 billing code.

If the correct code depends on patient details, such as age or sex, PCC EHR will automatically determine the code from patient information, as shown.

However, if a clinician selects a diagnosis that requires coding conventions, such as laterality or episode of care, PCC EHR will prompt the clinician to select an option.

After the clinician answers the questions, PCC EHR will present the correct ICD-10 billing code.

Later, the physician or biller can click “Bill” to review all procedure and diagnosis billing codes on an electronic encounter form. There they can adjust linking and make the encounter ready for billing.

You Will Not See These Tools For Charted Visits Prior to October 1st, 2015: The ICD-10 coding, as well as the laterality and episode of care drop-down menus, appear on chart notes for encounters after the October 1st, 2015 ICD-10 cut-over date.

Sex or Age Not on File?: If the patient’s chart does not include required sex or age information for determining an ICD-10 code, the clinician or biller can select the correct version of the code later, on the electronic encounter form or when posting charges in checkout.

Override and Configure the Billing Codes: Your practice can adjust the default billing code mapping for any diagnosis in the Billing Configuration tool. During charge posting, the biller can also change the codes if needed.

Use Auto-Notes to Insert Your Standard Text in a Chart Note Field

August 3, 2015/in Configure Other PCC EHR Features Configure PCC EHR /by Douglas Beagley

PCC EHR’s Auto-Notes feature can enter your default notes at the click of a button while you chart.

How Do I Use Auto-Notes?

When you click on a radio button selection while charting, or the “Make All” option at the top of the component, PCC EHR can auto-fill the notes field with your standard note.


For example, you may have a standard note for what “Normal” means for a physical exam. After you setup Auto-Notes, clicking on “Normal” or “Make All Normal” will add your notes to the chart note automatically. You can then review and confirm or revise the note text, as needed.

Each provider, or your whole practice, can implement standard notes for each choice (i.e. NL, ABN, N/E) for each radio-button style component, for each visit protocol. Read the sections below to learn more.

When you click on a new radio button selection, it will either replace the Auto-Note text with your alternate Auto-Note value, or erase the note text.


You can also re-click on a selection to deselect it, and PCC EHR will remove the Auto-Note text.


Your Changes Are Never Removed: If you make any change to a note text, PCC EHR will prefer your new note text and will not remove or update the note with the Auto-Note after that point. You can clear the note field to reset the Auto-Note behavior.

Set an Auto-Note

You can set an Auto-Note on the fly, as you chart.

First, make your radio button selection and enter your standard note for that selection.

Next, use your mouse to right-click on the note field and select “Set auto-note for…” from the contextual menu.

Not For Every Chart Note: Your auto-note settings are per-item, per-selection, and per-protocol. You may want a very different note for a teenage physical than for an infant, for example. Therefore, depending on your Protocol Map, you may need to set the same auto-note for several different visit reasons.

Enter and Edit All Auto-Notes

Use the Auto-Notes Configuration tool to edit or enter all of your auto-notes, for each radio component in each protocol.

First, run the Auto-Notes Configuration tool from the Tools menu.

Next, select a protocol and (optionally) a different user.

You can review all the radio line sections of the selected protocol. Use either the scrollbar or the anchor buttons to navigate. You can enter Auto-Note answers for each selection for each item, or indicate that you will use the Practice’s Default.

Not All Are Required: You may decide to only enter a “Normal” note for Physical Exam items, and leave the auto-note for “Abnormal” or “Not Examined” blank. You may decide to enter “Normal” auto-notes for just a few items on the chart note, and leave the others blank.

Edit Practice Default: To edit auto-notes for the Practice Default, select the “Practice” option from the User menu.


As you enter practice-wide Auto-Notes, keep in mind that every user and provider may be effected by your changes. Practice defaults should be discussed and agreed upon by all providers, and those PCC EHR users who wish to customize their own auto-notes (or use a blank field) should do so before you create practice-wide Auto-Notes.

You, the Practice, Other Providers: By default, all users have permission to edit their own Auto-Notes. The Auto-Notes Configuration Tool can also edit other providers’ Auto-Notes or enter default Auto-Notes for the entire practice. Permissions for Auto-Note configuration are set in the User Administration Tool. If you are unable to edit Auto-Notes, speak with your office’s PCC EHR system administrator.

Configure PCC EHR Session Timeout (Automatic Logout)

August 3, 2015/in Configure Other PCC EHR Features Configure PCC EHR /by Douglas Beagley

You can configure how long an inactive PCC EHR window will remain open. Set the session timeout length in the Practice Preferences window in the Configuration menu.


PCC EHR will close its windows when users leave their computers unattended for longer than the indicated time. Session Timeout is a feature required for HHS ONC certification, part of the ARRA/Meaningful Use rules.

Permissions: Access to the Practice Preferences is controlled through the PCC EHR User Administration Tool. Contact your office’s PCC EHR administrator if you need to set Practice Preferences.

Configure Vitals

August 3, 2015/in Configure Other PCC EHR Features Configure PCC EHR /by Douglas Beagley

Nurses and physicians measure vitals and enter them quickly into a patient’s chart. To make this process match your office’s workflow, you can configure PCC EHR’s temperature and blood pressure method defaults (oral, tympanic, right arm, etc.) as well as whether you use English or Metric measurements for other vitals.

You can also set whether vitals percentile calculations are based on WHO or CDC data, and turn on two weight management features.

These settings are system-wide and will be visible to all users of PCC EHR at your practice.

Set English/Metric and Default Methods

Follow the procedure below to set your practice’s default english/metric measurement preferences for vitals, as well as your default method of obtaining temperature and blood pressure.

Using Multiple Methods?: After setting default methods for temperature and blood pressure, users can still select a different method, on-the-fly, while charting. After setting English or Metric measurement, the alternative measurement will be displayed for your convenience.

Open the Protocol Configuration Tool

Click on the Tools menu and select the Protocol Configuration tool. Only authorized users have access to this program. Contact your office’s system administrator or PCC Support if you need help.


Click “Component Builder”

Select and Edit the “Vitals” Component

Select the Vitals component and click “Edit”, or double-click on the Vitals component to edit the settings for that component.

Set Your Defaults

Set any or all of your office’s Vitals configuration settings and default methods.

If your office does not wish to record a method by default, you can leave the blood pressure and temperature defaults set to “Unspecified”.

Click Save, Confirm, and Log Out

Save your work. You will see a confirmation screen for any changes you have made.

Click “Continue” to confirm your settings, and then close the Protocol Configuration tool.

Test Your Vitals Configuration

Open a new chart note for an existing, uncharted appointment and review the Vitals component. You can click the plus sign (+) to simulate entering a new measurement, or the “More” button if one of the Vitals items is not visible. Are your new settings taking effect?


Additionally, the Growth Charts section of the patient’s chart will use your practice defaults (English or Metric) for the axes of several charts and when entering historical growth points.

Configure Vitals Percentile Calculations and Growth Charts

In addition to setting how your practice collects and displays vitals, you can also set whether World Health Organization or Centers for Disease Control vitals data will be used to calculated vitals percentiles.

By default, PCC EHR displays percentiles and growth charts based on WHO data for patients under 2 years old and CDC data for patients over 2 years old.

You can set your office’s preferred data source for percentiles in the Practice Preferences tool.


The first option is PCC EHR’s default, as it matches the AAP’s current recommendation.

You can use the Growth Chart Configuration tool to select which charts are available in the patient chart.


You can click to drag and reorder charts into your office’s preferred order and turn any growth chart on or off.

After making your selection, the Growth Charts section of each patients chart will offer just those growth charts your office wishes to see, in the order you wish to see them.

Display Estimated BMI Calculations w/o Height

While height and weight are typically required for a BMI calculation, you might only collect weight at some visits.

PCC EHR can optionally display an “Estimated BMI” in the chart note when you only collect weight.

If a height was collected within a certain time range, PCC EHR will show the estimate BMI and also display when the height was last recorded. Estimate BMI will appear on the chart note as well as in the Visit History.

Off By Default: The Estimate BMI feature is turned off by default. You can enable it by editing the Vitals Component in the Component Builder section of the Protocol Configuration tool.

Optional BMI Range Labels

PCC EHR can optionally display a BMI range label below the BMI measurement in a chart note.

The Underweight, Healthy Weight, Overweight, and Obese range labels will only appear in the chart note while it is open. They will not appear in the Visit History, on the Patient Visit Summary, or anywhere else in the patient’s record.

Off By Default: The BMI Range Labels feature is turned off by default. You can enable it by editing the Vitals Component in the Component Builder section of the Protocol Configuration tool.

Configure Growth Charts

August 3, 2015/in Configure Chart Sections Configure Chart Sections /by Douglas Beagley

The Growth Charts section of a patient’s chart collects and displays vitals data across all of a patient’s visits, or manually entered vitals without a visit. Read the sections below to learn about the different configuration options for growth charts in PCC EHR.

Read the Growth Charts help article to learn about Growth Charts. Contact PCC Support at 802-846-8177 or 800-722-7708 for information about these or any features in PCC EHR.

Rearrange and Configure Which Growth Charts Appear in PCC EHR and the Patient Portal

Different growth charts appear in the patient’s chart automatically based on a patient’s age, sex, gestational age at birth (preterm), and (for Down syndrome) diagnoses in the Problem List.

Use the Growth Charts configuration tool to select which charts are available in the patient chart and adjust their order in the Growth Charts drop-down menu.


Click to drag and reorder charts into your office’s preferred order, and turn any growth chart on or off.

You can choose to share some or all of the same growth charts you use in PCC EHR with your families through the patient portal, or you can decide to disable growth charts in the portal entirely, through the Patient Portal Manager tool.

After you make your selections, the Growth Charts section of each patient’s chart (or the Growth Charts component in a chart note or in the patient portal) will offer just those growth charts your office wishes to show, in the order you wish to see them.

Define Which Diagnoses Activate the Down Syndrome Growth Charts and Vitals Percentiles

If a patient has a Down syndrome diagnoses in their Problem List, PCC EHR will automatically show Down syndrome growth charts in their chart, and will show all vitals percentiles based on Down syndrome patients of the same age and sex. You can define which diagnoses on a patient’s Problem List will qualify them as a Down syndrome patient.

Use the Growth Charts Configuration tool to add or remove Down syndrome diagnoses from the list of qualifying diagnoses.


On the “Down Syndrome Diagnoses” tab of the Growth Charts configuration tool, you can review and edit the list of SNOMED diagnoses that determine whether a patient’s chart will display the Down syndrome growth charts and Down syndrome vitals percentiles. Click in a blank field to add additional diagnoses.

Gestational Age at Birth and Fenton Preterm Growth Charts

If a patient’s gestational age at birth indicates prematurity (less than 37 weeks), PCC EHR will display Fenton Preterm growth charts.

Three different charts are available.

You can enter or update a patient’s “GA at Birth” in the Patient Demographics component, in the new birth history section.


ICD-9 758.0: The ICD-9 code set is no longer used in PCC EHR, but many patient Problem Lists may still only list the old 758.0 Down syndrome diagnosis code and not a newer SNOMED description. PCC added a checkbox to the Growth Chart configuration so that patients with the old diagnosis will also default to the Down syndrome growth charts and vitals percentiles.

Deactivate Down Syndrome Growth Charts and Vitals: Your practice can turn off all Down syndrome growth charts and the Down syndrome vitals percentiles by removing and deselecting all diagnoses from the Down Syndrome Diagnoses tab.

Add Growth Charts to Any Chart Note

You can add growth charts to your chart note protocols (or any ribbon), enabling clinicians to review growth chart information quickly while they chart a visit.

Use the Protocol Configuration tool to add the Growth Charts component to any chart note protocol.

Live Updating: If you enter new vitals into a chart note, as illustrated in the example above, click “Save” to update the growth charts in the chart note with the new vitals data.

Configure Vitals Percentiles for WHO or CDC Data Sets

By default, PCC EHR displays percentiles and creates growth charts based on World Health Organization (WHO) data for patients under 2 years old, CDC data for patients over 2 years old, and AAP Down syndrome data for patients who have a qualifying Down syndrome diagnosis on their Problem List. This configuration is based on the AAP’s guideline, but your office can change vitals calculations and change whether WHO or CDC data is used for patients.

Use the Practice Preferences tool to set your office’s preferred data source for percentiles.


The first option is PCC EHR’s default, as it matches the AAP’s current recommendation.

Set Your Preferred Data Collection Method to Metric or English Support

PCC’s growth charts match your practice’s preferences for how you enter vitals on a chart note. If you enter weight in kilograms on chart notes, then kilograms will appear on growth charts and when you enter historical data.

You can switch weight or another vital to the metric or English system, based on your practice’s preference. Run the Protocol Configuration tool and use the Component Editor to edit the Vitals component.


For a step-by-step guide to setting these preferences, read the Configure Vitals Defaults article.

Protocol Map: Assign Protocols to Providers and Visit Reasons

August 3, 2015/in Configure Chart Notes and PCC EHR Components Configure Chart Notes and Components /by Douglas Beagley

Use the Protocol Map to determine which protocols will be used for chart notes for specific visit reasons and providers.

After you have created a new protocol, or cloned an old one and made changes, you should adjust the Protocol Map so that the correct providers will see your new Protocol as the chart note for specific visit reasons.

Open the Protocol Map

To get started with the Protocol Map, open the Protocol Configuration tool. Then click “Protocol Map”.

Review the Protocol Map

The Protocol Map indicates which protocol will be used to create the chart note for each visit reason, for each provider.

All of your practice’s visit reasons are listed on the left-most column. In the central column, either “All” or a particular provider is designated. The protocol that will create the chart note appears in the right-most column.

For example, for all visits of type “Sick”, all providers will use the “Bright Futures – Sick” protocol to create the chart note, except for Dr. Beverly Crusher, who prefers a custom Sick protocol.

Assign a Different Protocol to Visit Reasons and Providers

Select a visit reason and click “Edit”, or double-click on any entry to change the behavior for that visit reason.


Use the drop-down menu at the top to change the default protocol used for the indicated visit reason. In the spaces below, choose a provider and an alternate protocol to indicate exceptions.

Configure Demographics

August 3, 2015/in Configure Chart Sections Configure Chart Sections /by Douglas Beagley

The Demographics section of a patient’s chart displays patient and family demographics, such as patient information, contact information, insurance policies, and siblings.

Follow the procedure below to open the Demographics Builder and make changes to your office’s layout for the Demographics section of the chart.

Open the Protocol Configuration Tool

Click on the Configuration menu and select the Protocol Configuration tool.


Limited Access: Permission to login to the Configuration Tool is controlled through User Administration. Speak to your office’s PCC EHR system administrator or contact PCC Support if you need access.

Open the Demographics Builder

Click the Demographics button to edit the Demographics chart section.

Review Current Components

Review the list of components currently visible on the Demographics section of the chart.

Click and Drag to Adjust the Order of Components

You can click and drag items on the screen to rearrange them.

Hide Components

Select any component and click “Hide Component” to remove it from your office’s Demographics layout. The next time any user opens a chart, the hidden component will not appear.

What About Existing Content?: PCC EHR will notify you if any charts contain data in the component you wish to hide. You may then decide to Hide or Cancel.

If you decide to hide a component that contains data, the patient information is not lost. It will reappear if you add back the component.

Add Components

Click Add Components and select an available component to add it to your office’s Demographics layout.

If no components are visible on the drop-down list, then your Demographics chart section contains all available components.

Configure Component Anchor Buttons and Label

Select any component and click Edit to adjust contents, anchor buttons and button text.

For all components, you can indicate whether or not the component should have an anchor button and what the anchor button text should be. Some components have additional display options.

Optional: Add Additional Demographics Fields

You can add multiple birth indicator, mother’s maiden name, and additional patient identifiers to the Patient Demographics component. Use the Chart Wide Components section of the component builder to edit the Patient Demographics component.

Optional: Create a New Demographics Component

If you need to record other chart information and have it appear on the Demographics section of the chart, you can create additional notes field. Use the Component Builder to create a new Medical Summary Component, and then add that component to the Demographics section of the chart.


You can edit the name and also indicate whether the component should have a flip-down privacy triangle, like Confidential Notes.

After creating a new component, add that component to your Demographics layout using the instructions in the steps above.

Save Your Work

The Protocol Configuration tool saves your work automatically. Click “Main Menu” to return to the main menu, or simply close the window to log out.

Configure the Medical Summary

August 3, 2015/in Configure Chart Sections Configure Chart Sections /by Douglas Beagley

The Medical Summary appears when you first open a patient chart. It may include a Problem List, a Medication history, and many other useful components.

Follow the procedure below to open the Medical Summary Builder and make changes to your office’s layout for the Medical Summary section of the chart.

Open the Protocol Configuration Tool

Click on the Tools menu and select the Protocol Configuration tool.


Limited Access: Permission to login to the Configuration Tool is controlled through User Administration. Speak to your office’s PCC EHR system administrator or contact PCC Support if you need access.

Click on Medical Summary Builder

Click the Medical Summary Builder button to edit the Medical Summary chart section layout.

Review Current Components

Review the list of components currently visible on your office’s Medical Summary.

Click and Drag to Adjust the Order of Components

You can click and drag items to rearrange them.

Hide Components

Select any component and click “Hide Component” to remove it from your office’s Medical Summary layout. The next time any user opens a chart, the hidden component will not appear.

What About Existing Content?: PCC EHR will notify you if any charts contain data in the component you wish to hide. You may then decide to Hide or Cancel.

If you decide to hide a component that contains data, the patient information is not lost. For example, if you stored Social History notes for a couple of patients but then decided to remove it from your Medical Summary, PCC EHR would notify you, and then hide the component. The Social History information would still be stored in PCC EHR’s database, and it will reappear if you add back the component.

Add Components

Click Add Components and select an available component to add it to your office’s Medical Summary.

If no components are visible on the drop-down list, then your Medical Summary contains all available components.

Configure Components Anchor Buttons and Label

Select any component and click Edit to adjust contents, anchor buttons and button text.

For all components, you can indicate whether or not the component should have an anchor button and what the anchor button text should be.

For other components, such as the Recent and Upcoming Appointments component, you can configure the contents of the component.

Optional: Create a New Medical Summary Component

By default, PCC EHR includes Reminders, Social, Family, and Medical History, and a Confidential Notes field on your Medical Summary. You can also use the Component Builder to create custom note or history fields for any purpose.


You can edit the name and also indicate whether the component should have a flip-down privacy triangle, like Confidential Notes. Note that you can also add the confidential feature to any existing medical summary component, such as the Family and Social history fields.

After creating a new component, add that component to your Medical Summary using the instructions in the steps above.

Save Your Work?

The Protocol Configuration tool saves your work automatically. Click “Main Menu” to return to the main menu, or simply close the window to log out.

Fulfill Orders and Complete Tasks

August 3, 2015/in Create and Complete Procedures, Referrals, Labs, and Other Orders Create and Complete Orders /by Douglas Beagley

The sections below explain how to fulfill orders in PCC EHR. Orders include labs, immunizations, referrals, screenings, radiology, and medical procedures.

Read below to learn how to find and manage open orders, how to edit them, and how to enter results and create follow-up tasks.

Find and Manage Open Orders

Before you can work on an order, you must find it. PCC EHR includes several different ways to find the orders you need to work on:

  • Open the Patient Chart
  • Use the Tasks Column on the Schedule Screen
  • Use the Visit Tasks Queue (or the Messaging Queue)
  • Run Reports in the Report Library

Read the descriptions below to learn about the features of each method.

Method 1: Review Outstanding Tasks as You Review a Patient’s Chart

When you are on the phone with a family or working in their chart for another reason, you can use the following methods to identify incomplete tasks and work on them.

Outstanding Tasks Component

The Outstanding Tasks component, which appears on the Medical Summary by default, shows you all outstanding tasks for the patient. Icons indicate if the task is attached to an order, phone note or document. You can add this component to other sections of the chart or protocols as well.

Click on a task icon to go directly to the task.

Highlighted Components Contain Outstanding Tasks

The anchor button for any component, protocol or section in a patient’s chart that has an outstanding task displays in orange. Click on the anchor button to open the chart section or component that contains the outstanding task.

Tasks in the Visit History Index

The Tasks column in the Visit History component uses icons to indicate which encounters contain outstanding tasks. Hover your mouse over each icon to view a summary of the tasks, or click on the icon to go directly to the task. Visits with completed tasks will show icons with green check marks.


Method 2: Use the Tasks Column on the Schedule Screen to Fulfill Orders

You can use the Tasks column on the Schedule screen to locate and work on any orders for a visit.

The indicators tell you if the visit has any incomplete orders.

An incomplete order could be an incomplete task, a missing lab result, or an immunization that needs to be administered.

Click on the tasks indicator to access the orders and work on them.


Click “Edit” to work on any order. See below for an example.

Twice in One Day, or Multiple Days: The Schedule screen, Tasks column, and Edit Orders window deal with each appointment separately. Therefore, if a patient has multiple visits on a single day or across several days, you should look at each appointment entry to check their Task column. Or, use the Visit Tasks queue to review and work with all incomplete orders.

Method 3: Use the Visit Tasks Queue to Fulfill Orders

The Visit Tasks queue is a robust, powerful tool that makes managing your outstanding tasks a snap. You can set up defaults that let you watch just the providers or assigned users you wish, and you can switch quickly between a list of all orders, all incomplete orders, or other display criteria.

Click on the “Visit Tasks” tab to view the Visit Tasks Queue. You can see various order tasks, including immunizations, lab orders, and medical procedures. By default, you will only see tasks that are past their “Due” date, meaning that they are ready to be completed now.

Double-click on any order to open it and work on the tasks, enter lab results, or administer immunizations. (For examples, read the “Edit and Fulfill Different Kinds of Orders” section below.)

Filter the List of Tasks/Orders: As you review the list of incomplete tasks, use the filters at the bottom to limit which tasks appear. You can see tasks of specific types, locations, assigned users, provider of encounter, or of certain statuses (Not Complete, Complete).

After setting your preferences, click “Save My Defaults” and PCC EHR will remember how you like to use the Visit Tasks queue.

Run a Report to Find Open Orders

In addition to the features and tools described above, you can also use PCC EHR’s Report Library to find and manage patient labs, referrals, and other orders.

For example, to create a list of all open orders of a specific type (such as referrals), run the Orders By Visit report.

You can create custom orders in the Report Library to work with any kind of order, complete or incomplete.

Edit and Fulfill Different Kinds of Orders

After you find and open an order, you can make changes, enter results, and complete tasks. Read the sections below to learn more.

Generate and Send Information to a Third-Party Health Care Provider

For some orders, you might need to send a form, contact a referral provider, or perform similar actions. How do you get information about an encounter to another health care provider?

Tailor the information to your audience! Generate a lab or radiology requisition, send a Direct Secure Message, or use the Patient Visit Summary, the Health Information Summary, or a custom form to get information out about an order.

Enter Required Results

When you work on some orders, you will notice some fields that are required for completion. Required fields are highlighted in orange.

A typical lab order will contain one or more tests, with may require results as shown above. The order will be listed as incomplete until the required fields are filled. Many orders have no required results.

Complete and Create Tasks

For an order to be complete, all tasks must be complete. If an order has tasks, they appear below (or instead of) result fields.

Click “Task Completed” to mark a task as done. You can also create additional follow-up tasks and assign them back to the provider or another user. (Your practice can customize which users can be assigned tasks in the User Administration tool.)

Tasks are optional. Your practice can use them to indicate that a nurse should collect a specimen, a physician should review results, or a staff member should prepare a handout. However, labs with discrete test results have a built-in Lab Order task that appears on the Visit Tasks queue automatically. Your office may decide it doesn’t need an additional task to know that labs are complete.

Due Dates: You can optionally give any task a due date. You might complete a task today, but create an additional task that will be done in the future. When a task is not due today, the order will appear with the orange ring indicator, so you can tell at a glance that it is task for the future, and not due today.

Default or "Sticky" Tasks: When you add a task to an order, PCC EHR remembers it. The next time you create the same order, that task will appear automatically. This is called a “sticky” task. PCC EHR remembers sticky tasks per order, per user, so if your office is using a new type of order for the first time, each clinician may need to add the Collect Specimen task (for example) the first time they create that order.

Remove a Task, Remove a Sticky Task: You can remove any task by blanking out the “TASK” field and the “TO” field and saving the order. If your office decides to no longer use tasks for a particular order, each ordering clinician can blank out those fields the next time they place that order to remove the default sticky task.

Lab Specimen Collection Information

Lab orders include optional specimen collection information.

Click the checkbox to automatically enter your name and the current date and time. You can then adjust or update the information with the correct user, date, or time.

When recorded, specimen collection information appears on the Edit Orders window, on the View Details lab report, in the Visit History, and in the Sign Orders window. Specimen collection information is part of the CLIA lab standard and will support PCC’s future integration with lab services.

Configuration: By default, the specimen collection feature appears in all of your labs. You can use the Lab Configuration Tool to turn the specimen collection fields off for any lab order.

Require a Signature, Cancel an Order, Make Other Changes

As you edit an order, you can make other changes that effect the order.

Needs Review and Signature?: Click the “Signature Required” checkbox to indicate that an order needs to be signed. It will then appear on the Signing queue. From there, clinicians can review and sign the results, and optionally create order follow-up tasks.

Cancel an Order: After grabbing an order, either from the Visit Tasks queue or the chart, you can click “Canceled” to cancel it.

Hide an Order from Public Reports and the Patient Portal: At any time, you can deselect the “Visible on Patient Reports” checkbox to hide the order from the Patient Visit Summary, the Health Information Summary, and the Patient Portal.

Click Save Order or Save: After you make changes, click the Save Order button, or (if the chart is open) the Save button, to save your changes.

Fulfill Immunization Orders

Immunization Workflow Guides: In addition to the reference materials below, you can read or watch Review, Order, and Administer Immunizations (Article, Video).

When you fulfill immunization orders, you can enter detailed information related to an immunization, including the patient’s VFC eligibility, the dose, lot, VIS information, as well as the route and site of administration.

Lots in PCC EHR: By selecting a lot number, you enter all information about the lot, including expiration date and manufacturer. If you need to add or deplete an immunization lot, you can open the Vaccine Lot Manager right from the Lot # pull-down menu.

Using Barcode Scanners to Select Lots:

If you use barcode scanners to track inventory, you can use the Scan Vaccine Lots button in the Immunization Orders component, or the “Scan” button within each order to scan your vaccines. Read more about using barcode scanners to manage your vaccine inventory.

Wherever possible, PCC EHR will remember your practice’s defaults, current lot number, and previous answers and help you. For example, once someone in your office selects a specific VIS for a shot…


…PCC EHR will remember your office location’s standard VIS form for that shot and you won’t have to select it each time. One user can select the VIS forms the first time, and from then on each user at your office can simply confirm that the VIS is given. When a new VIS form becomes available, select it once to make it sticky for all subsequent users.

After entering details, you can click Administered, Refused, Contraindicated, or Canceled to complete the order.


If you click in error, you can click a different choice or click again to deselect your choice. The “Completed/Administered by” fields will be filled out automatically with your username and the current date and time, but you can change them if you are entering information later.

If you mark an order as Refused or Contraindicated, you can enter a reason.

Read the Configure Immunizations in PCC EHR help article to learn more about immunization lots.

Complete Order Follow-up Tasks

If a physician creates a task on an order in the Sign Orders window, the nurse or other clinician will find it on the Messaging queue along with phone notes and other messages. They can double-click to open up the Order Follow-Up task.


Just like phone notes, an Orders Follow-up note is a customizable ribbon. By default, it contains the lab test results and all the information needed to call the patient or family, discuss the results, or perform other actions related to the order.

Order Follow-up notes also appear in the patient’s Visit History, for later review.

Order a Lab, Procedure, Supply, or Other Order

August 3, 2015/in Get Started Create and Complete Procedures, Referrals, Labs, and Other Orders Create and Complete Orders /by Douglas Beagley

As you review a chart note, take a phone call, or perform an exam, you may create orders. For example, the patient may need referrals, shots, a nebulizer treatment, a handout, or a lab. Click “Order” to create an order.

The procedure below shows some of the details and tools you might use when you create orders.

Open a Patient Chart and Today’s Chart Note, a Phone Note, or a Portal Message

First, open the patient’s chart. Double-click on the patient’s name on the Schedule, the Messaging queue, or use the Find field.

If the patient has a visit today, a chart note will open for you. Otherwise, you might review a portal message, create a new Phone Note, or review another encounter in the Visit History.

No Appointment?: If the patient has no appointment and no chart note for today, you can click “Create Visit” and select a visit reason in order to start a chart note and request a lab or other order. You can also open a previous encounter in the Visit History section of the chart.

Jump to the Desired Section of the Protocol (Referrals, Lab Orders, Medical Procedures, etc.)

The navigation buttons for the protocol often include a direct link to “Labs”, or other orders components. (You can also scroll down to find what you need.)

Common orders components include Follow-Up Orders, Handout Orders, Lab Orders, Medical Procedure Orders, Medical Test Orders, Radiology Orders, Referral Orders, Screening Orders, Supply Orders, and Surgical Procedure Orders. Immunizations is a special orders component that includes a history and other features.

Add a Visit Protocol for More Order Options: If today’s chart note does not include the type of orders you need, you can select “Add Protocol” from the Edit menu and add a visit protocol that will include the orders you need. Your practice can customize protocols for each of your visit reasons and other encounters.

Click Order

Click “Order” next to the order you need. Or, begin typing in the blank pull-down and then select the order and click “Order”.

You can work with PCC Support to customize the list of labs and other orders available for each chart note protocol.

Snap Labs: Some orders may be “Snap” orders, which pop in several orders with a single click. For more information, read the Lab Configuration guide.

Immunizations: You can order immunizations just as you would any order. The patient’s immunization record, and optionally an Immunization Forecasting section, appear inline to help you determine what immunizations are needed. Your custom chart note may list common immunizations for today’s visit. Also, a special VFC section will provide patient information and let you enter the patient’s VFC eligibility for all the immunizations in this visit.

Click “Edit” to Edit Order Details

Click “Edit” to change your order defaults, add details or make the order more specific.


You can change the order date and enter notes. You can assign a specific user or user group to complete the order, and enter a “Due” date so the order will appear as “not due today”, and will become due after a specific date.

Depending on the order type, you can also enter other information (such as specimen collection and source information, lab facility, or results) immediately, if applicable. For example, immunization orders include details about VFC, VIS, whether a shot was administered or refused, and other options.

For each order, you can also turn on or off three important status items.

  • Signature Required: The order will appear on the signing queue for clinician review.

  • Refused, Contraindicated, and Canceled: Select one of these items when an order will not be completed. It will not appear on any task queue or the Edit Orders window. The order will still appear on the chart note, but be marked appropriately.

  • Privacy: Include on Patient Reports: If this box is selected, the order will appear on patient reports and will be available in the patient portal. Deselect this box to make the order “confidential”, and only visible within PCC EHR.

Optional: Add or Edit an Order Task

Labs and other orders may include tasks. Click “Add Task” to create a task for an order.

Choose a task name from the customizable drop-down list, and optionally assign the task to a specific user. (All tasks must have a task name, a user, or both.)

Tasks appear wherever the order appears, and your practice can track and complete tasks in many ways: from the orange orders indicator on the Schedule queue, the Visit Tasks, or the Outstanding Tasks component in a patient’s chart.

Tasks are optional. Your practice can use them to indicate that a nurse should collect a specimen, a physician should review results, or a staff member should prepare a handout. However, labs with discrete test results have a built-in Lab Order task that appears on the Visit Tasks queue automatically. Your office may decide it doesn’t need an additional task to know that labs are complete.

Default or "Sticky" Task: When you add a task to an order, PCC EHR remembers it. The next time you create the same order, that task will appear automatically. This is called a “sticky” task. PCC EHR remembers the first sticky task per order, per user. If your office is using a new type of order for the first time, each clinician may need to add the Collect Specimen task (for example) the first time they create that order.

Remove a Task, Remove a Sticky Task: You can remove any task by blanking out the “TASK” field and the “TO” field and saving the order. If your office decides to no longer use tasks for a particular order, each ordering clinician can blank out those fields and save the order. The next time they place that order, the task will not appear.

Who Can Be Assigned Tasks?: You can customize whether a user can be assigned tasks on the Account Information tab in the User Administration tool. For example, you may want to grant all nurses the “Tasks can be assigned to this user” attribution, or you may want to remove the attribute for nurses who do not complete orders.

Optional: Use Multiple Tasks, Add Due Dates to Tasks

You can add multiple tasks to an order. For some orders, you might create a single task and assign it to someone in your office. When they are done, they might create an additional task and assign it back to you, or to someone else at your practice. In this way, work that needs to be done for a single order (such as a lab test), is all kept within the order itself.

You can optionally give any task a due date. You might complete a task today, but create an additional task that will be done in the future.

When a task is not due today, the order will appear with the orange ring indicator, so you can tell at a glance that it is task for the future, and not due today.

Optional: Add Other Information You Need for the Order

Labs or referrals may require a diagnosis. If you are creating an order on a Phone Note, you may need to enter location and provider information. After you create orders, you may need to enter other information that supports the order.

Optional: Fulfill the Order Immediately, Send Out the Order, and More

You can click “Edit” and complete an order (by entering test results or completing order tasks) immediately, as soon as you order it.

You can also find and complete order tasks later on the Visit Tasks queue, from the orange task indicator in the Tasks column on the Schedule queue, or from the Outstanding Tasks component in a patient’s chart. To learn more, read Fulfill Orders and Complete Tasks.

Send Order Information Out to a Lab, Hospital, or Other Third-Party: For some orders, you might need to send a form, contact a referral provider, print a lab requisition, or similar. Your practice can use PCC EHR’s Forms component, Direct Secure Messaging, the Patient Visit Summary, the Health Information Summary, or generate a requisition to get information out about an order.

Manage Incoming E-lab Test Results

August 3, 2015/in Create and Complete Procedures, Referrals, Labs, and Other Orders Create and Complete Orders /by Douglas Beagley

Your hospital or a 3rd-party lab vendor (such as LabCorp or Orchard Trellis) can send lab test results directly to PCC EHR. Read the procedures below to learn how to import an e-lab result into a patient chart, delete an incoming test result sent to your practice in error, or return an e-lab result back to the queue.

Does PCC Interface With My Hospital or Lab Vendor?: Before PCC EHR can receive lab test results, your practice must have an active interface with that lab provider. PCC offers dozens of lab interfaces, and we can work with your lab vendor to develop a new connection. For more information, visit PCC Interoperability, or contact PCC Support at 800-722-7708.

Video: Watch how to Add E-lab Users and Import E-lab Results.

Import an E-Lab Test Result

Use the procedure below to review incoming e-lab results and attach them to a patient’s chart and a specific encounter and order.

Open the Queue of Incoming E-lab Results

When you are ready to work with incoming lab results, click on the E-lab Results tab to view the queue.


The files in this queue come from lab vendors, so the patient names and clinicians may not precisely match those in your system.
While viewing this queue, you can click on any column header to sort. You can also filter the list by Provider.

Select a Results File

Double-click on any results file to open it.

Review Results File

After opening a results file, you can read a summary of its contents.

On the Summary tab, you can see basic patient and order information. Click on the Result Details tab to review more information about the lab results, or click on the Report of Record tab to see the original file as formatted by the lab vendor or hospital.

Select a Patient

PCC EHR will automatically search for the patient and display the best matches. Double-click to select the patient.

Optionally, you can use the Find field to find any patient.

Select a Visit

Next, select the specific visit during which the orders were created.

By default, PCC EHR will show you all visits that contain matching lab orders so you can select the correct appointment.

Sometimes your practice may receive e-lab results that do not match an order in the patient’s chart. You can pick any visit with labs from the vendor, or pick another visit.

Import an Order w/ No Visit?: If a hospital or lab vendor sends unsolicited lab results to your practice, or “copies” results to you from a different care provider, you can place those results into the patient’s chart without selecting a visit date.


After choosing “Accept unsolicited…”, you will be prompted to select a provider. You may also need to select a facility if you have more than one facility from that vendor.

Verify Matching Orders, Select Alternatives or Create Missing Orders

After you select a visit, PCC EHR will match the e-lab results with the patient’s orders.

If all matching is complete and correct, you can click Save to finish and return to the queue.

If a match does not look correct, or no matching order was found, you can use the pull-down menus to specify an order. You can pick an existing order from the selected appointment, create an order of the suggested type, or create any order for the same vendor.

Save and Continue

Click Save to finish the import and return to the E-lab Results queue.

Next Steps: Review e-Lab Results in the Patient’s Record

After importing e-lab results, clinicians and other users can review results wherever they look at lab orders. Results will be visible on the Signing queue, for the physician’s review and signature, and they will appear on the chart note in the patient’s Visit History. Results will also appear on the patient’s Flowsheets.

Next Steps: Sign Results, Create Phone Tasks

All e-lab results appear on the Signing queue for the physician’s review.

From the signing queue, the physician can review results and optionally create a follow-up phone task.

Phone Tasks will appear on the Messaging queue, where nurses and other clinicians can respond to the task and take action.

Delete an Incoming E-Lab Test Result

When your practice is sent an e-lab result that is not for your patient, you should delete it and inform the sender.

Not Reversible: Deleting an incoming e-lab result is permanent. No record remains on your PCC EHR database. Double-check the patient information and speak with the referenced provider before deleting.

Determine Who Has Permission to Delete an E-Lab Result

Since deleting an e-lab is a permanent erasure of medical information, your practice should only grant delete permissions to a specific role at your practice. The first step in deleting an e-lab result might be to figure out who has that permission.

Your practice’s System Administrator can open the User Administration tool and grant the “E-lab Result Deletion” permission to a role. Then they can assign that role to specific users.

For more information, read Configure User Roles and Permissions.

Alternatively, find a colleague who has permission to delete e-labs. Ask them to delete the result. They can use the steps below.

Find and Open the E-Lab Result You Wish to Delete

Visit the E-lab Results queue, find the e-lab sent to your practice in error, and double-click to open it.

Review Ordering Provider and Patient Name

Deleting an e-lab result is permanent. Before you delete an e-lab result, double-check that the patient is not associated with your practice and that the provider is not affiliated with your practice. If appropriate, contact the ordering provider.

Click “Delete Result”

Click the “Delete Result” button to delete the e-lab result.

Confirm Deletion

Review the warning alert and click “Delete” to confirm deletion.

Unlink E-lab Results from a Patient or Encounter

You can unlink electronic laboratory results that were attached to the wrong patient or encounter and send them back to the E-lab Results queue.

Video: Watch how to Unlink an E-lab Result from a Patient’s Record.

Open the Unlink E-lab Results Tool

Open the Unlink E-lab Results tool from the Tools menu in PCC EHR.

By Permission Only: Users must have a role that has the “E-lab Result Unlinking” permissions in order to access the Unlink E-lab Results tool. You can configure user roles and permissions in the User Administration tool in PCC EHR.

Find the Result to Unlink

In the Unlink E-lab Results tool, find the result that needs to be unlinked. Use the Imported Date Range and Search Filter fields to focus your search.

You can use the Search Filter to search by the patient name reported in the e-lab result, the user who linked the result to a patient in PCC EHR, the test orders included in the e-lab result, the name of the laboratory that ran the tests, the name of the patient who was linked to the result, the date of the encounter that the result was attached to, or the name of the protocol that the result was attached to.

Unknown User: If the user who linked a lab result displays as “Unknown”, it indicates that the result was imported prior to your practice receiving PCC 9.7. All e-lab results received and linked to patients after PCC 9.7 will be attributed to the user who did the linking.

Select and Unlink the Result

Once you find the result that needs to be unlinked, select it from the list then click the “Unlink” button.


Confirm your selection, then close the Unlink E-lab Results tool.

Relink the E-lab Result to the Correct Patient and Encounter

Unlinked e-lab results return to the E-lab Results queue in PCC EHR, where they can be relinked to the correct patient and encounter.

To learn how to link e-lab results to patients and encounters, jump to Import and E-lab Test Result.

Orders Overview (Labs, Procedures, Supplies, Immunizations, and More)

August 3, 2015/in Get Started Create and Complete Procedures, Referrals, Labs, and Other Orders Create and Complete Orders /by Douglas Beagley

As you work with a patient in PCC EHR, you can order labs, x-rays, screenings, injections, supplies, medical procedures and tests, surgical procedures, handouts, and follow-up tasks. Select the appropriate items in the patient’s chart note and click “Order”. Then click “Edit” to enter details or modify tasks for that order.

Later, any nurse or provider can complete the tasks and optionally enter notes and results. They can do so right on the chart note, or with a quick link from today’s schedule, a dynamic Visit Tasks queue, or a special “Outstanding Tasks” component in the chart.

For a guide to charting a visit, including creating orders, visit Chart a Visit.

For more detailed information about requesting, fulfilling, and canceling different kinds of orders and their tasks, read the topics listed below.

What is an Order in PCC EHR?: An order can be anything done for a patient. You create an order when you click “Order” for a lab, but you may also create orders for giving a handout or requesting a vision screen. Standard order types include labs, medical or surgical procedures, handouts, injections, radiology, screening, and supplies. Your practice can create custom orders for any purpose. All orders use the same kind of interface in the chart, and orders may have one or more tasks that can be picked up and completed elsewhere in PCC EHR.

Review and Revise Orders and Lab Results

August 3, 2015/in Create and Complete Procedures, Referrals, Labs, and Other Orders Create and Complete Orders /by Douglas Beagley

You may need to review complete lab results, print them out with all details, or even remove an order that was recorded in a patient’s record by mistake. Read the sections below to learn all the options for reviewing lab and order information.

What is an “Order”?: An order is anything done for the patient. You create an order when you click “Order” for a lab, but you may also create orders for giving a handout or requesting a vision screen. Standard order types include labs, medical or surgical procedures, handouts, injections, radiology, screening, and supplies. All orders use the same kind of interface in the chart and may have one or more tasks that appear on the Visit Tasks queue.

There are many different ways to review a patient’s orders and results.

Review Today’s Orders

First, you can click on the Tasks column on the Schedule queue to open all the orders for a particular visit. This is particularly handy when you want to review orders that occurred today.


Read the Visit History or Open the Chart Note

You can review order notes and/or lab results in the Visit History at any time. You can select a visit, click edit, and make changes to the order right on the old chart note.

As a user makes changes to an order, PCC EHR records the usernames of anyone who took notes or entered other order details. You can review those attributions in the Visit History or on the chart note.

If you need a Lab order report that meets CLIA audit regulations, or wish to review all available materials related to an order, click “Details”.


Track Order and Result History in Flowsheets

You can also review the results of many orders, such as lab tests, in the Flowsheets section of the patient chart. While reviewing results, you can click on the order name to review even more details.

Review Immunization History

Immunizations are a special kind of order. You can review a patient’s entire immunization history in the Immunizations History section of the patient chart.


Patient Reporting

Some order details and test results appear on patient reports, such as the Health Information Summary and Patient Visit Summary. They also appear on the Patient Portal, which the patient can log into remotely.


Only orders that are marked “Include on Patient Reports” will appear. You can hide an order from patient reports and the Patient Portal by deselecting the “Include on Patient Reports” checkbox.

Report – Orders by Visit

Use the Orders by Visit report to find open orders for a specified date range, or all orders of a specific type. This report displays orders associated with appointments, and can be filtered by provider, order name, order status, and location.

Add Age-Appropriate Immunizations to a Chart Note Protocol

August 3, 2015/in Configure Chart Notes and PCC EHR Components Configure Chart Notes and Components /by Douglas Beagley

Follow the steps below to use the Protocol Configuration tool to add your practice’s age-specific immunizations to your Well Child chart note protocols.

Protocol Builder Example: This procedure demonstrates the Protocol Builder, PCC EHR’s tool for editing your practice’s custom chart notes. You can use the steps below to make other changes to a chart note protocol. For more information, read the other Protocol Configuration Tool help articles. Contact PCC Support for help or suggestions.

Open the Protocol Configuration Tool

Click on the Configuration menu and select “Protocols”.

For more information, read Open the Protocol Configuration Tool.

Click “Protocol Builder”

Select a Well Child Visit Protocol

From your practice’s list of chart note protocols, select the first one that could be used for a patient who might receive immunizations. Double-click to edit it.

You could start with the earliest Well Child visits and work through all of them. You may want to add common “catch up” immunizations to your protocols for later Well Visits, and not just add those that fit the normal immunization schedule.

Preview a Protocol: You can click “Preview” or “Used By” to study the protocol you have selected. For more information, read Protocol Builder Reference.

Select and Edit the “Immunizations” Component

Find the Immunizations component on the list of components. Double-click on it or select it and then click “Edit”.

If the Immunizations component is not on the chart note protocol, you can click “Add” to add it.

Add the Age-Appropriate Immunizations or Catch-Up Immunizations a Clinician Might Order During This Visit

Click “Add Items” to select specific immunizations that will appear by default on this chart note.



Use the drop-down menus to select the immunization(s), and click “Add”. Click “Save” when you are finished.

Edit Available Immunizations or Add Combination Vaccines?: The list of available immunizations in PCC EHR comes from the your Procedures table and your underlying immunization configuration. Contact PCC Support for help editing immunizations or adding new combination vaccines.

Repeat the Above Steps for Each Chart Note Protocol

Repeat the above steps for each chart note protocol that may be used with a patient who could require immunizations.

CVX, MVX, VIS and NDC Codes in PCC

August 3, 2015/in Configure Other PCC EHR Features, Immunizations Configure PCC EHR /by Douglas Beagley

The CDC maintains lists of vaccines, their manufacturers, VIS publications, and NDC codes. With each immunization you administer, PCC stores this information and validates it based on the CDC’s lists.

Many PCC features, such as immunization forecasting and immunization registries, rely on these codes to uniquely identify each immunization that your practice administers. Additionally, CVX and MVX codes are part of the HL7 standard and are referenced by incentive programs and other initiatives.

Learn More About CVX, MVX, VIS, and NDC Code Tables Maintained by the CDC

You can review the lists of these values, along with some useful mapping tables, online at the cdc.gov web site:

  • MVX: The Manufacturers of Vaccines list published by the CDC.

  • CVX: The Vaccine Administered list published by the CDC.

  • VIS: The Vaccine Information Statements list published by the CDC, which also includes EUA or Emergency Use Authorization information statements.

  • NDC Crosswalk Tables: The National Drug Code crosswalk tables published by the CDC.

  • CVX by CPT: The CDC’s mapping of CVX codes to CPT billing codes.

  • Product Names By CVX/MVX: The CDC’s mapping of product names to CVX and MVX codes.

How Does PCC Update Your System’s CVX, MVX, VIS, and NDC Lists?

Your practice’s PCC server automatically updates vaccine information validation lists from the CDC.

When the CDC makes changes to the official MVX or CVX codes, or to the VIS or NDC lists for vaccines, your system automatically retrieves the latest versions and makes them available to your PCC tools.

These codes ensure your ability to accurately track vaccines that you order, administer, bill, and submit to immunization registries and other third parties. For example, when a new Vaccine Information Statement is released, you can indicate that you are distributing it inside an immunization order. When you enter details for an immunization, PCC software checks against these lists to ensure the value is valid.

Enter CVX, MVX, and Other Vaccine Details for the Vaccines You Administer

When you add a new vaccine or new formulation of a vaccine to your fridge, you should review the brand name and NDC code. You can use the resources above to identify the CVX and MVX codes for the vaccine. Use this information when you enter vaccines into the Immunization Lot Manager, or when you select a VIS as you administer the vaccine, for example.

Contact PCC Support at support@pcc.com or 802-846-8177 or 800-722-7708 to add a new immunization or adjust your system’s immunization configuration. PCC Support can help add the immunization to your forms, walk you through your order configuration so the correct procedures are automatically billed, and more.

To learn more about immunization configuration, read Configure Immunizations in PCC EHR.

Open the Protocol Configuration Tool

August 3, 2015/in Get Started Configure Chart Notes and PCC EHR Components Configure Chart Notes and Components /by Douglas Beagley

Use the Protocol Configuration tool to customize your chart notes, the behavior of PCC EHR components, or to adjust the Medical Summary, Patient Checkin, or other PCC EHR protocol-based screen. Click on the Configuration menu and select “Protocols” to open Protocol Configuration.


Permissions and User Access

  • Limited Access: Permission to open the Protocol Configuration tool is controlled through User Administration. Speak to your office’s PCC EHR system administrator or contact PCC Support if you need access.

  • One at a Time: Only one user at your practice may edit protocols at a time. If you are unable to open Protocol Configuration, another user at your practice may be using the tool.

Order Configuration Examples

August 3, 2015/in Configure Chart Notes and PCC EHR Components Configure Chart Notes and Components /by Douglas Beagley

Read the examples below to learn how to create or edit an order, set default behaviors, and add specific LOINC tests for charting.

For more information about order components and how they work in chart notes, read the Component Builder and Component Reference help articles.

Lab Orders and Immunizations are Different than Other Orders: You can create and edit most kinds of orders in the Component Builder as shown in the procedure below. However, you must create and edit lab orders in the Lab Configuration Tool, and new immunizations must be configured in your Procedures table and in your practice’s underlying immunization configuration. Contact PCC Support for assistance.

Create or Edit a Depression Screening Order with Discrete Results

If you are applying for PCMH or another incentive program, you may want to configure a depression screening order so that it includes discrete results. The order will then be a more useful way to chart depression screening results, and it will help you meet a CQM requirement. Read the example below to see how to make these or similar changes.

Open the Component Builder

First, open the Protocol Configuration tool and click on “Component Builder”.


Find and Open the Order Component

Open the Screening Orders component to review your existing screening orders.

Order components all have the term “Orders” at the end of their name. They include Follow-Up Orders, Handout Orders, Lab Orders, Medical Procedure Orders, Medical Test Orders, Radiology Orders, Referral Orders, Screening Orders, Supply Orders, and Surgical Procedure Orders.

Edit or Add a New Order to the Component

If you do not already have a depression screening order, click Add to create one. Or, select an existing order and click Edit.

Name Your Order and Set Parameters

Give your order a name and set basic parameters. Will the order be included on patient reports by default? Can the order be refused or contraindicated?

As with lab orders, you can check boxes in order to set whether an order can be Contraindicated or Refused, as well as set the default privacy (“Include on Patient Reports”) setting.

Optional: Add a Corresponding SNOMED Procedure Description For Reporting

Click “Add Procedure” to link a SNOMED description to the order for reporting purposes. For example, you may add a SNOMED code to orders for additional adolescent evaluations, follow-ups, and referrals in order to collect data for meeting Clinical Quality Measures.

Add One or More Tests to the Order

Click “Add a Test” to add one or more LOINC tests to the order. For depression screenings that meet the CQM guidelines, you could add the “Adolescent depression screening assessment” test, as shown.



Other Tests to Add, Other Depression Screenings: Your practice can use other screening tests that match the workflow at your practice, either in a single order or in multiple orders. For example, every question in the PHQ-9 depression screening has a corresponding LOINC entry. Your practice could add each question in PHQ-9. Or, you could create a PHQ-9 order for recording and tracking the patient’s total score.

By using discrete test result fields in screenings, you will be able to track the patient’s score over time in the patient’s flowsheets.

Add the Order Component and the Order to Specific Chart Notes

After creating your order, you can add it to specific chart notes.

First, add the component to a chart note protocol if it does not already appear. Next, edit the component and add the order.

For more information, read the Protocol Builder help articles.

Configure Billing for Your New Order

After creating your order, open the Billing Configuration tool to map appropriate billing codes to the order.


When a user creates the order on a patient’s chart note, the mapped billing codes will automatically appear on the encounter form.

For more information, read the Billing Configuration article.

Configure Radiology Orders with Discrete Results

If you’d like a way to enter standardized results for x-rays, you can add discrete radiology tests to your radiology orders.

Just as with the depression order example above, you can add or edit your radiology orders in the Component Builder. You can set default behaviors for the order and add corresponding LOINC tests.



Protocol Builder Reference

August 3, 2015/in Configure Chart Notes and PCC EHR Components Configure Chart Notes and Components /by Douglas Beagley

Use the Protocol Builder, inside the Protocol Configuration Tool in the tools menu, to customize the chart notes, phone notes, and other encounter-based ribbons that your clinical staff work with every day.

Getting Around

After you Open the Protocol Configuration Tool, click on “Protocol Builder” to create or edit a chart note protocol.


The Protocol Builder displays a list of all of your practice’s current protocols. From this screen you can preview your protocols, find out who uses each protocol, and create, clone, and edit the contents of each protocol. Read the reference sections below to learn more about each option.

For step-by-step examples of editing protocols, read Add Specific Imms to a Protocol or Create and Edit a New Protocol.

Main Menu

Click “Main Menu” to go back one step, to the main screen of the PCC EHR Configuration Tool.

Preview

Select a protocol and click “Preview” to see an approximation of what a protocol will look like when you are charting a visit.


While previewing, you can cycle through your other protocols with the controls at the top of the screen. Click “Close” to return to the Protocol Builder menu.

Print a Draft of Your Chart Notes: You can click “Print” while previewing a chart notes in the Protocol Configuration Tool to print a copy. If you are creating and revising protocols for your office, you can print hard copies and hand them to your providers for review.


Clone or Add a New Protocol

When you want to create a new chart note protocol, the easiest method is to clone an existing protocol and then make changes. Often, you want to tweak an existing protocol for a single provider, or work on changes for a new version of a protocol without affecting the one that is currently in use.

Click on a protocol and then click “Clone”.


Copy Auto-Notes: Your practice or an individual clinician can create auto-notes, which make charting faster, easier, and more consistent. When cloning a protocol, you can decide whether to copy existing auto-notes into place or not. If you are not certain, answer “Yes” to this question so that users will have the option of continuing to use existing auto-notes.

Alternatively, if you want to create a protocol from scratch and start with a blank chart note, click “Add New Protocol”.



You can then begin to add components. For an example of adding and configuring components, read Create and Edit a Protocol.

Assign Your Protocol: Creating a new protocol does not assign it to appear for a provider or visit reason. You must create and add components to your protocol and then use the Protocol Map tool to determine when it will appear for charting.

Review Which Providers Use a Protocol

Select a protocol and click “Used By” to see all the providers who use this protocol, and which visit reasons use it. Protocols can be used for more than one visit reason.


For the visit reasons listed on the left, the selected protocol will be used to create the chart note for the providers on the right. You can use the Protocol Map to change which providers use which protocols.

Note: If a protocol is used for “All” providers for a particular visit reason, that indicates it is the default protocol. Other protocol settings for specific providers may override the “All” listing. Check the Protocol Map to be certain.

Edit a Protocol

Select a protocol and click “Edit” to open the protocol for configuration.


While editing, you can add, delete, or “Edit” (configure) components that make up the protocol. For examples of adding and editing the components in protocols, read Add Specific Imms to a Protocol and Create and Edit a New Protocol.

Select any component and click “Edit” to make changes.


What can you do while configuring a component in a protocol?

  • Set Anchor: Any component in a protocol may appear as one of the navigation buttons on the left hand side of the screen while charting. While editing a component, you can indicate that it should have an anchor navigation button.

  • Change Title: You can edit the title of the component, which also appears as the title of the anchor button, if applicable.

  • Set Filter for Answer Memory: The “Filter” setting controls which set of past answers (the Provider’s or Patient’s) will appear as pull-down options while charting. In most cases, this should be set to “Provider”. You may wish to change it to “Patient” for patient-specific social history questions.

  • Add (or Delete) Items: Most components have a list of items within them. The “History” and “Review of Systems” components will have different items in different protocols, and you can add different labs to the Labs component, if you wish. Click “Add Items” and select new items from a drop down list. If you need something that is not available at all, such as a brand new lab or question, first use the Component Builder to edit the component.

For more information about the different settings available for each kind of component, read Component Reference.

Add Chart-Wide Components to a Chart Note Protocol

August 3, 2015/in Configure Chart Notes and PCC EHR Components Configure Chart Notes and Components /by Douglas Beagley

You can add many special components, which appear elsewhere in a patient’s chart, to your customizable chart note protocols. These include siblings, growth charts, Recent and Upcoming Appointments, any Medical Summary component, and any Demographics component.

If you configure these components to appear in a chart note, your clinicians can review and edit important information without navigating elsewhere in the chart.

Use the Protocol Configuration tool to edit your chart note protocols and add these components.

Chart-Wide Information vs. the Visit Chart Note: Special components, such as growth charts, Demographics, and Medical Summary components, are chart-wide. You can use them to review patient information irrespective of visits. You can configure your visit protocols to include these components, but they are not appended to the visit’s chart note that appears in the Visit History.

Edit Chart-Wide Components from the Chart Note: When added to a chart note protocol, users can click “Edit” to make changes to most Medical Summary and Demographics components.

Note that some Medical Summary components appear with “(Medical Summary)” after the title.

For a complete list of special components and all components available on custom chart notes, read the Component Reference help article.

Chart Note Configuration Introduction

August 3, 2015/in Get Started Configure Chart Notes and PCC EHR Components Configure Chart Notes and Components /by Douglas Beagley

PCC EHR’s Protocol Configuration Tool creates and edits custom chart notes, phone notes, and order follow-up notes in PCC EHR.

You can design and edit components, or the “building blocks” for a chart note, in the Component Builder. Next, you can use the Protocol Builder to assemble those components into protocols and configure their onscreen behavior. Finally, the Protocol Map controls which protocols will be used to generate chart notes for provider visits.

Good custom protocols lead to faster and more efficient charting and result in more consistent care for patients. PCC Software Support will provide both initial training on the PCC EHR Protocol Configuration Tool and ongoing support as your providers adapt PCC EHR to their workflow.

By learning about protocol configuration, you will gain the ability to tweak and refine your chart notes and improve your PCC EHR experience.

Check Out Awesome Examples: PCC hosts a web site displaying protocols created by pediatric practices around the country. You can review these award-winning chart notes at protocols.pcc.com.

Component Reference

August 3, 2015/in Configure Chart Notes and PCC EHR Components Configure Chart Notes and Components /by Douglas Beagley

Components are the building blocks of protocols, which are used to create chart notes for visits, and other sections of the patient chart. By understanding the different component types and the available specialized components, you will be able create useful new sections for your chart notes and configure them.

Read the sections below to learn more about each component type and the various options available when creating or configuring. For more information about creating a new component, read the Component Builder article. For more examples of adding and configuring components in protocols, see the other Protocol Builder articles.

Chart-Wide Components

Many of the components in PCC EHR are “chart-wide” components, which means that they can appear in multiple places within the patient chart. When data is added or edited in one place, the same information is updated simultaneously wherever else that component appears.

Chart-wide components can be added to the following sections of the patient chart:

  • Medical Summary
  • Demographics
  • Patient Check-In
  • Patient Details (Appointment Book practices only)
  • Visit Protocols
  • Phone Notes

The Medical Summary and Demographics sections of the chart are made up exclusively of chart-wide components. You may find it useful to also include some of these components in visit notes, phone notes, or other places in the chart. For example, your practice may choose to include the Recent and Upcoming Appointments component on the Medical Summary, the Phone Note protocol, all well-visit protocols, and even on your Patient Check-In ribbon.

Account Balances

The Account Balances component shows an overview of outstanding personal charges for the patient’s billing account.

The balances are account-based, so you can see total overdue amounts for this patient and any siblings who share the same billing account.

Unpaid balances are broken down into Personal, Insurance, and Medicaid charges. They are aged across aging categories (0-29 days, 30-59 days, etc.), with the total personal balance due displayed in red.

Click the disclosure triangle to view a summary of the charges that have an outstanding personal (non-insurance) balance.


If you’d like to print a copy for the patient or family, click Print.


In addition to balance details, the printout includes your practice’s information as well as the date it was generated.

The Account Balances component appears in the Patient Check-In window by default, but you can add it to chart sections, chart notes, the Patient Details window, phone notes, or any location where it would be useful for your practice.

Account Demographics

The Account Demographics component is used to keep track of a patient’s Home and Billing account(s).

Some patients may live with one parent, but the other is financially responsible, so they would have one Home account and one Billing account, whereas other patients might only have one account for both Home and Billing.

The Account Demographics component appears in the Demographics section of the chart by default, but you can also add it to the Medical Summary, the Patient Check-In ribbon, the Appointment Details ribbon (if your practice uses the Appointment Book), any visit protocol, and phone notes.

Learn about creating and assigning accounts in PCC EHR by reading the Add New Patients and Accounts article.

Account Notes

Use the Account Notes component to record details about an account or billing situation with a family.

Allergies & PCC eRx Allergies

PCC EHR has two distinct allergy components, the Allergies component and the PCC eRx Allergies component.

You can use the Allergies component to record any non-drug allergy. The PCC eRx Allergies component has special features for handling drug allergies.

You can edit the Allergies component wherever it appears in the patient chart. The PCC eRx Allergies component is updated inside PCC eRx, the prescriptions section of a patient’s chart.

When allergies are up-to-date, PCC EHR can automatically warn you about drug allergies as you prescribe, create lists of patients based on allergies, and display custom alerts whenever you work with a patient’s chart.

Both the Allergies and the PCC eRx Allergies components appear on a patient’s Medical Summary by default, but you can also add either or both to the Demographics sections of the chart, the Patient Check-In ribbon, the Appointment Details ribbon (if your practice uses the Appointment Book), any visit protocol, and phone notes.

For more information about working with allergies in PCC EHR, read the Allergies article.

Appointment History

The Appointment History component is available for practices who use the Appointment Book. This component displays a list of appointments for a patient, both past and future, including canceled appointments.

Details for each appointment can be viewed by highlighting the appointment and clicking the Details disclosure triangle.

You can reschedule or cancel appointments directly from this component.

The Appointment History appears on a patient’s Medical Summary by default, but you can also add it to the Demographics sections of the chart, the Patient Check-In ribbon, the Appointment Details ribbon (if your practice uses the Appointment Book), any visit protocol, and phone notes.

Care Plan

The Care Plan component can be used to manage a patient’s progress with a chronic condition, mental health issue, or anything that a patient regularly sees a specialist for.

Care plans can be reviewed and updated at each well visit, or as labs or reports come in from relevant specialists.

You can add a Care Plan to the Medical Summary or Demographics sections of the chart, the Patient Check-In ribbon, the Appointment Details ribbon (if your practice uses the Appointment Book), any visit protocol, and phone notes.

Care plans are a requirement for PCMH and are recommended by some payers. You can use it to meet the NCQA guidelines for meeting the requirements of PCMH.

For more information about using care plans, read the Use a Patient Care Plan to Improve Care for Chronic Patient Issues article.

Communication Preferences

The Communication Preferences component is used to indicate how a family prefers to be contacted, and whether they wish for their data to be shared with immunization registries.

Patient Reminders and the Patient Notification Center both use the patient’s confidential communication preference.

The Communication Preferences component appears in the Demographics section of the chart by default, but you can also add it to the Medical Summary, the Patient Check-In ribbon, the Appointment Details ribbon (if your practice uses the Appointment Book), any visit protocol, and phone notes.

Confidential Notes

The Confidential Notes component provides a place in the patient’s chart where clinicians can write notes that are only meant to be seen by certain staff.

Information stored in the Confidential Notes component will not print out on any reports, including the Health Information Summary, Patient Visit Summary, or the Summary of Care Record. It will not appear anywhere in the patient portal.

The Confidential Notes component is collapsed by default, which means that any notes that have been written do not appear visibly on the screen when a chart is opened. The person reviewing the chart will have to click on the arrow to expand the note section, and read whatever has been written.


You can add the Confidential Notes component to the Medical Summary or Demographics sections of the chart, the Patient Check-In ribbon, the Appointment Details ribbon (if your practice uses the Appointment Book), any visit protocol, and phone notes.

You can copy a confidential note from one sibling’s chart to another’s. See the Siblings component overview below for more information.

For more information about using confidential notes, read the Confidential Notes and Other Confidential Fields article.

For more information about patient privacy and making certain items confidential, read the Patient Privacy Features article.

Family History

The Family History component is used to enter relevant family history for a patient.

You can add the Family History component to the Medical Summary or Demographics sections of the chart, the Patient Check-In ribbon, the Appointment Details ribbon (if your practice uses the Appointment Book), any visit protocol, and phone notes.

The Family History component is a simple entry field that expands as text is added.

You can copy family history from one sibling’s chart to another’s. See the Siblings component overview below for more information.

Family Medical History

The Family Medical History component is used to chart medical history for family members.

You can add the Family Medical History component to the Medical Summary or Demographics sections of the chart, the Patient Check-In ribbon, the Appointment Details ribbon (if your practice uses the Appointment Book), any visit protocol, and phone notes.

In edit mode, you can click on a blank field to add a new condition and relationship.

For each condition, you can select a diagnosis from your practice’s Family History list, or right-click to search the SNOMED diagnosis list. Next, you can indicate one or more family members who have the diagnosis, and enter notes. The relationship field comes from a standardized HL7 list of relationships.

You can copy a family’s medical history from one sibling’s chart to another’s. See the Siblings component overview below for more information.

For more information about working with a family’s medical history, read the Family Medical History article.

Forms (Patient and Account)

The Patient and Account Forms components can be used to generate patient and account forms in PCC EHR. This component can improve form letter workflow for practices by making sure the right forms appear on the right protocols.

You can configure which forms will appear by default for “one click” generating. You can choose to have different forms appear in different sections of the patient chart. The Patient and Account Forms components will always display a drop-down menu of all available forms.

The Patient and Account Forms component appears on a patient’s Medical Summary by default, but you can add this component to the Demographics sections of the chart, the Patient Check-In ribbon, the Appointment Details ribbon, visit protocols, phone notes, and portal messages.

To learn more about generating and configuring forms in PCC EHR, read the Generate Forms or Configure Forms articles.

Growth Charts

The Growth Charts component collects and displays vitals data across all of a patient’s visits. Different growth charts appear in the patient’s chart automatically based on their age, sex, and certain diagnoses.

Growth Charts appear in the History section of a patient’s chart by default, but you can add them to the Medical Summary, Demographics section, the Patient Check-In ribbon, the Appointment Details ribbon (if your practice uses the Appointment Book), any visit protocol, and phone notes.

PCC EHR plots patient data on each chart and also indicates percentile averages with gray lines. Percentile ranges are specific to a patient’s age and sex, and come from the World Health Organization (WHO) and the Centers for Disease Control (CDC).

PCC EHR updates growth charts automatically when you enter vitals on a visit chart note.

For more information about growth charts, read the Review a Patient’s Growth Chart and the Configure Growth Charts articles.

Insurance Eligibility

The Insurance Eligibility component primarily functions as an encounter-specific component. A more limited version is available on any protocol, however, for use when checking eligibility before a patient has an encounter.

See Insurance Eligibility below.

Medical History

The Medical History component is used to enter relevant medical history for a patient.

You can add the Medical History component to the Medical Summary or Demographics sections of the chart, the Patient Check-In ribbon, the Appointment Details ribbon (if your practice uses the Appointment Book), any visit protocol, and phone notes.

The Medical History component is a simple entry field that expands as text is added.

You can copy medical history from one sibling’s chart to another’s. See the Siblings component overview below for more information.

Medication History

The Medication History component shows all of a patient’s prescribed and reported medications.

Each medication is displayed along with its dosing statement and instructions, as well as the start and stop date of each prescription.

At the top of the list, you can see when the patient’s medications were last updated, and beneath the list you can see when it was last marked as reviewed.

The Medication History appears on a patient’s Medical Summary by default, but you can add this component to the Demographics sections of the chart, the Patient Check-In ribbon, the Appointment Details ribbon (if your practice uses the Appointment Book), any visit protocol, and phone notes.

To learn more about working with a patient’s medication history, and how it interfaces with PCC’s prescribing tool, PCC eRx, read Review and Update Medication History.

Outstanding Tasks

The Outstanding Tasks component shows all outstanding tasks for a patient. Icons are used to indicate if the task is attached to an order, phone note or document.

Outstanding Tasks appear on a patient’s Medical Summary by default, but you can add this component to the Demographics sections of the chart, the Patient Check-In ribbon, the Appointment Details ribbon (if your practice uses the Appointment Book), any visit protocol, and phone notes.

To learn more about completing tasks in PCC EHR, read Fulfill Orders and Complete Tasks

Patient Demographics

The Patient Demographics component displays important patient information, including unique identifiers, birth history data, patient flags associated with the patient, the name of their primary care physician, and other demographic data.

The Patient Demographics component appears in the Demographics section of the chart by default, but you can also add it to the Medical Summary, the Patient Check-In ribbon, the Appointment Details ribbon (if your practice uses the Appointment Book), any visit protocol, and phone notes.

Learn about updating patient demographic information in PCC EHR by reading the Review and Update Patient and Family Demographics article.

Patient Portal Users

The Patient Portal Users component can be used to quickly review portal information and help the family with patient portal access.

You can see if mom, dad, or another guardian has access to the patient’s records. If the patient has no portal account users, you can click “Add Portal User” to jump into the Patient Portal Manager.

If the family has not logged in, doesn’t have a linked billing account, or needs their password reset, you can click “Manage Portal User” to open up the Patient Portal Manager and help the family with their accounts.

For more information, read Patient Portal User Account Administration.

Personal Contacts

The Personal Contacts component can be used to list contact information for a patient’s family members, guardians, or other relations.

The Personal Contacts component appears in the Demographics section of the chart by default, but you can also add it to the Medical Summary, the Patient Check-In ribbon, the Appointment Details ribbon (if your practice uses the Appointment Book), any visit protocol, and phone notes.

Learn about updating personal contact information in PCC EHR by reading the Review and Update Patient and Family Demographics article.

Policies

The Policies component is used to add, update, and work with a patient’s insurance policies and medicaid plans in PCC EHR.

The patient’s primary policy appears at the top, with a “1”, and any secondary or tertiary policies appear as well. All active policies are displayed by default.

For full policy information you can click the disclosure triangle to the left of each policy.


The Policies component appears in the Demographics section of the chart by default, but you can also add it to the Medical Summary, the Patient Check-In ribbon, the Appointment Details ribbon (if your practice uses the Appointment Book), any visit protocol, and phone notes.

Learn about creating and managing a patient’s insurance policies in PCC EHR by reading the Update Patient Insurance Policies article.

Problem List

The Problem List component shows a list of issues for a patient. The list is created using SNOMED-CT diagnosis descriptions.

The Problem List appears on a patient’s Medical Summary by default, but you can also add it to the Demographics sections of the chart, the Patient Check-In ribbon, the Appointment Details ribbon (if your practice uses the Appointment Book), any visit protocol, and phone notes.

You can add or remove problems, and rearrange problems.

You can add problems directly to the Problem List component, or while charting the diagnosis during a visit.

For more information about working with a patient’s problem list, read the Problem List article.

Recent and Upcoming Appointments

The Recent and Upcoming Appointments component displays read-only information about a patient’s appointments at your practice, including their most recent well child visit, and when they are next due for a physical.

You can add the Recent and Upcoming Appointments component to the Medical Summary or Demographics sections of the chart, the Patient Check-In ribbon, the Appointment Details ribbon (if your practice uses the Appointment Book), any visit protocol, and phone notes.

The component can display the last visit (including diagnoses), last and next physical dates, and any upcoming scheduled appointments. You can display or hide each of these items wherever the Recent and Upcoming Appointments component appears, to best suit your office’s workflow needs.

Reminders

The Reminders component can be used to note important issues related to a patient that everyone who opens the chart should see.

If the patient needs something done during a follow-up visit or has a pressing concern or issue, you can use the Reminder text field to help your office coordinate care around that issue.

You can see when the reminder was last updated by checking the modification date next to the component name.

You can add the Reminders component to the Medical Summary or Demographics sections of the chart, the Patient Check-In ribbon, the Appointment Details ribbon (if your practice uses the Appointment Book), any visit protocol, and phone notes.

You can also copy reminders from one sibling’s chart to another’s. See the Siblings component overview below for more information.

Siblings

The Siblings component includes a list of patient siblings and a button for opening their chart.

You can add the Siblings component to the Medical Summary or Demographics sections of the chart, the Patient Check-In ribbon, the Appointment Details ribbon (if your practice uses the Appointment Book), any visit protocol, and phone notes.

Click “Open Chart” to open a sibling’s chart side-by-side with the current chart. You can open up to four sibling charts at once.


Some chart-wide components, such as Reminders, Social/Family/Medical History, and Confidential Notes, may contain information that should be added to a sibling’s chart as well.

When you want to copy a note field to a sibling, right-click on the note and select “Copy (Component Name) to Siblings”.

For more detailed instructions on copying information to sibling charts, read the Medical Summary article.

For more information about working with multiple sibling charts, read the Review and Edit Sibling Charts article.

Social History

The Social History component is used to enter relevant social history for a patient.

You can add the Social History component to the Medical Summary or Demographics sections of the chart, the Patient Check-In ribbon, the Appointment Details ribbon (if your practice uses the Appointment Book), any visit protocol, and phone notes.

The Social History component is a simple entry field that expands as text is added.

You can copy social history from one sibling’s chart to another’s. See the Siblings component overview above for more information.

Order Components

PCC EHR includes the following order components: Follow-Up Orders, Handout Orders, Lab Orders, Medical Procedure Orders, Medical Test Orders, Radiology Orders, Referral Orders, Screening Orders, Supply Orders, and Surgical Procedure Orders.

Each of these pre-configured components have buttons for creating orders that may trigger tasks. They incorporate all of PCC EHR’s tools for completing orders and tasks.

After you click “Order” in one of these components while charting, you can edit and complete the order, either in the chart note or elsewhere in PCC EHR.

Orders may include discrete LOINC result fields, they can include notes, have tasks added to them, and they can be marked with various statuses (Signature Required, Refused, etc.)

Here is a Depression Screening order, seen while the user is editing it.

This order includes a discrete LOINC test (Adolescent depression screening assessment) that requires a result to be complete. Currently, no clinician signature is required, the order is not refused, contraindicated or canceled, and the order is allowed to appear on patient reports (and in the patient portal). The user can change any of these settings. Your practice can define default behaviors for these settings in the Component Builder.

Use the Component Builder to add new procedures, handouts, referrals, and other items that can be ordered and can trigger tasks.

To read more about orders in PCC EHR, review the Orders Overview article.

Encounter-Specific Components

PCC EHR has several pre-defined components for accomplishing specific tasks while charting a patient encounter.

Each of these pre-configured components contains fields filled out for specific needs. For example, the Vitals component data populates PCC EHR’s growth charts.

Can I Edit These Components?: You can’t create new components of these types. However, you can:

  • Use the Protocol Builder to add any of the specialized components to your protocol.
  • Use the Protocol Builder to determine exactly which items appear within the component for that specific protocol. Your protocols can display exactly the vitals that you collect for a specific age, for example.
  • Use the Component Builder to adjust other behavior for components. For example, you can clear out the answer memory for a component in the Component Builder.

Diagnoses

The Diagnoses component, used for charting today’s diagnoses, has special features including a link to the built-in electronic encounter form and tools for adding diagnoses directly to a patient’s Problem List.

For help working with diagnoses in the patient’s chart, read the Find and Refine Diagnoses as You Chart article.

For information about how to configure diagnoses in PCC EHR, read the Diagnosis Configuration article.

Diagnoses to Rule Out

The Diagnoses to Rule Out component is used to chart diagnoses that are being ruled out as part of the patient visit. The drop-down list includes the same diagnoses as included in the Diagnoses component, although diagnosis from the patient’s current problem list do not appear at the top. In addition, there are no indications that a diagnosis is “private”, as rule-out diagnoses are not included in patient reports, by default.

Encounter Billing Notes

Use the Encounter Billing Notes component to record details specific to the billing for an encounter.

Immunizations

The Immunization component displays a patient’s immunization history and also displays a custom pick list of immunizations for the specific protocol (often configured by age). At practices where a bidirectional immunization registry interface has been established, the Immunization component also allows you to look up and import a patient’s immunization records from the registry.

A user can click to create an order for an immunization, and it will include special fields for recording immunization data.

For help working with immunizations in the patient’s chart, read the Review and Update a Patient’s Immunization Record article.

For more information about configuring immunizations in PCC EHR, read the Immunizations Configuration help article.

Insurance Eligibility

The Insurance Eligibility component is used to review patient insurance eligibility for active policies.

When the component appears in Patient Details, the Medical Summary, or another protocol that is not specific to an encounter, it includes limited features and can only submit a request for eligibility based on today’s date.

When the Insurance Eligibilty component appears in Patient Check-in, a chart note, when posting charges, or another encounter-specific protocol, it has more functionality and allows the user to manually record a status, date verified, and notes, all of which will be associated with the encounter.

When you first open the Patient Check-In protocol, PCC EHR automatically checks eligibility, if it has not already been done. The Eligibility Response will display either “Active” in green, to indicate that the patient is covered, or “Inactive” in red, meaning that the patient is not currently covered.

For more information about Insurance Eligibility, read Patient Insurance Eligibility with PCC.

Prescriptions

The Prescriptions component will appear within a patient’s chart note if prescriptions have been added through PCC eRx during the visit. This component will only appear if medication is prescribed during the specific visit.

For more information about prescribing in PCC EHR, review the PCC eRx documentation on learn.pcc.com.

Time of Service Payments

The Time of Service Payments component is used during the check-in process in PCC EHR to post a payment toward the family’s account balance. The amount due today will appear in a ledger.

This component is account-specific, so if the patient has siblings, you will see all of the family’s current and past-due balances. The account balance will automatically update as you post payments, and you can also print a receipt to give to the family.

For more information about how to use the Time of Service Payments component, read the Check In a Patient article.

Visit Documents (Documents component)

When you add the Documents component to a visit protocol, the Visit Documents component will appear within a patient’s chart note if there are any documents that have been imported into the chart and associated with the open visit. This component will only appear if there are documents for the specific visit.

For each document, you can see a thumbnail of the image, any notes or tags attached to the document, and if it is related to a specific order. You can see whether the document was shared in the portal, if it is awaiting a signature, and any associated tasks.

Clicking on the “View Document” button will open the Document Viewer, where you can sign the document, complete or add new tasks, print, or delete the document.

Visit the Working with Documents help article to learn more.

To see other areas of the chart where documents appear, read the Review Documents for a Patient article.

Vitals

The Vitals component contains special fields for collecting vitals, and includes automatic calculations for percentile and BMI. The Vitals component data populates PCC EHR’s growth charts.

You can configure vitals in PCC EHR for each type of visit protocol. You can customize which fields will appear by default for the visit, determine whether to use English or Metric measurement values, and decide how to calculate BMI values.

Once entered, vitals will show up immediately, everywhere that vitals are displayed. You can edit any vitals that you entered, and you can see who entered other vitals by hovering over the vitals measurement.

For information about how to configure vitals in PCC EHR, including how vitals interact with growth charts, read the Configure Vitals article.

Meaningful Use (ARRA) Components

Adult Weight Management

The Adult Weight Management component is used to evaluate the adult weight management measure. When added to a protocol, this component will only appear for patients who are eighteen years old or older

In order for PCC EHR to accurately calculate your numbers for this CQM, you should record height and weight for all patients 18+ years old and, for those patients with BMI outside of the CQM guidelines, document your care goal and follow-up plan using diagnoses and procedures on the electronic encounter form.

Additionally, you can enter dietary consultation information or indicate why a visit’s BMI is unusual with the new Adult Weight Screening and Follow-Up (ARRA) component.

For more information, you can read a guide to running the CQM report, or a guide to Meeting CQM with PCC EHR.

Asthma Care

The Asthma Care component can be used to track when a patient or parent requests not to receive an asthma medication.

This field is a component of the HL7 C-CDA standard medical record, and supports PCC EHR’s Last Answer feature for quick entry.

Cognitive Status

The Cognitive Status component is a simple entry field that expands as text is added. This field can be added to your visit chart notes to meet Meaningful Use requirements for recording cognitive status for patients.

This field is a component of the HL7 C-CDA standard medical record, and supports PCC EHR’s Last Answer feature for quick entry.

Functional Status

The Functional Status component is a simple entry field that expands as text is added. This field can be added to your visit chart notes to meet Meaningful Use requirements for recording functional status for patients.

This field is a component of the HL7 C-CDA standard medical record, and supports PCC EHR’s Last Answer feature for quick entry.

Smoking Status

The Smoking Status component stores a patient’s answer to smoking status questions as defined by Meaningful Use guidelines.

The 2011 standards for the ARRA Medicaid EHR Incentive program required the tracking of this data for each patient visit. While the more recent and finalized “Meaningful Use Stage 2” standards do not include this requirement, and you do not need to submit reporting around it of the ARRA Medicaid EHR Incentive program, it is still considered best practices. If a pediatric practice attests for the program and is later audited, they must show that they collected smoking status for patients 13 years old and older.

The Office of the National Coordinator for Health Information Technology (ONC) defines the status options and definitions.

Status Definition
Never Smoker has not smoked 100 or more cigarettes during
his/her lifetime
Current Every Day Smoker smoked at least 100 cigarettes during his/her lifetime and still regularly
smokes every day
Current Some Day Smoker smoked at least 100 cigarettes during his/her lifetime and still regularly
smokes periodically
Former Smoker smoked at least 100 cigarettes during his/her lifetime but does not currently smoke
Heavy Tobacco Smoker greater than 10 cigarettes per day or an equivalent (but less concretely defined) quantity of cigar
or pipe smoke
Light Tobacco Smoker less than 10 cigarettes per day, or an equivalent (but less
concretely defined) quantity of cigar or pipe smoke
Smoker, Current Status Unknown known to have smoked at least 100
cigarettes in the past, but their whether they currently still smoke is unknown
Unknown If Ever Smoked Unknown

Transition of Care

The Transition of Care component tracks whether a medication reconciliation was performed when a patient was received from another setting of care, as defined by Meaningful Use guidelines.

If you are meeting with a new patent, or if your established patient was seen elsewhere since their last visit with you, check the boxes to indicate that a patient has transitioned into your care, and that you performed a medication reconciliation.

For more information, refer to Objective 7: Medication Reconciliation, as described in the the Meet Meaningful Use Measures with PCC article.

Custom Components

PCC EHR gives you the tools to make your own components, so that you can decide exactly what information you want to track for your patients, and how you want to collect that data. Following are several types of components that you can build yourself.

You will also notice that you probably already have a number of these “Generic” components listed in your Component Builder, as PCC EHR includes a number of components that were built to go within certain protocols, for example, the Bright Futures protocols that many PCC clients choose to use.

You can get a sense for what types of new Generic components you can create by reviewing the ones you already have.

Generic Header

The Generic Header component is a simple title. You can add it to any protocol to serve as a divider between sections on your chart note.

Following is an example of a Generic Header component, used within a Bright Futures sick visit protocol:

Creating a Generic Header Component

When creating a new Generic Header component, you need only enter the title of the header.

When you add a Generic Header component to a protocol, you can indicate whether or not the component should have an anchor button for navigation and set the anchor text.

Generic Text Edit

The Generic Text Edit component is a large text box. You might use a Generic Text Edit component if your chart note needs a large area for notes. It is suitable for paragraphs and longer text-entry.

Following is an example of a Generic Text Edit component, used within an Asthma visit protocol:

Generic Text Edit components do not use “answer memory”; use components of this type when you need a notes box that is unlikely to be precisely repeated for another visit.

Creating a Generic Text Edit Component

When creating a new Generic Text Edit component, you need only enter the name of the section.

When you add a Generic Text Edit component to a protocol, you can indicate whether or not the component should have an anchor button for navigation.

Generic Note

The Generic Note component is for simple text notes. They appear as a single line, but can contain as much text as needed.

Following is an example of the two types of Generic Note components, used within a sick visit protocol:


Generic Note components use “answer memory”, either based on the provider or the patient. PCC EHR remembers the answers that you type into a chart note and then supplies a list of previous common answers.

Use the Generic Note component when you want a place for the provider to enter simple notes that may be reused.

Creating a Generic Note Component

When creating a new Generic Note component, you need to enter the name of the section, and indicate if it should provide single or unlimited input fields.

Single or Multiple?: A “Single” Generic Note will provide only one line of text for entry. A “Multiple” Generic Note will add additional lines of text as you type, so you can enter a series of notes.

When you add a Generic Note component to a protocol, you can indicate whether or not the item has an anchor button for navigation, and you can set whether answer memory should be filtered by provider, patient, or unfiltered.

Generic Check

The Generic Check component displays a list of items with checkboxes next to them. While charting, a user can check or uncheck items in the list, and add notes for each item that will be stored in “answer memory”, either by provider or by patient.

Following is an example of a Generic Check component, used within a well visit protocol:

If the “Display last saved answer” option was checked for the component (before the particular patient was checked in), then you will see the most recent saved note as well:

Creating a Generic Check Component

When creating a new Generic Check component, you must name the component and then add the list of items that will be available for the component.


You can also indicate that the component should display the patient’s last answer on the chart note.

For more information about creating and editing components, read The Component Builder.

Adding a Generic Check Component to a Protocol

When you add a Generic Check component to a protocol, you must specify which of your list of items will be available by default on the chart note. You can also indicate whether or not the item has an anchor button for navigation, and you can set whether answer memory should be filtered by provider, patient, or unfiltered.


For more information about working with components in protocols, read Create and Edit a Protocol.

Generic QA

A Generic QA component contains a list of questions with text boxes for recording the answer. The text box field uses “answer memory” and will provide a drop-down menu of past notes based on the provider or the patient.

Following is an example of a Generic QA component, used for newborn well visits:

Creating a Generic QA Component

When creating a new Generic QA component, you must name the component and create a list of possible questions and answers.


You can also indicate that the component should display the patient’s last answer on the chart note.

Adding a Generic QA Component to a Protocol

When you add a Generic QA component to a protocol, you must indicate which questions should appear by default on the chart note. You can also indicate whether or not the item has an anchor button for navigation, and you can set whether answer memory should be filtered by provider, patient, or unfiltered.


Generic Radio

A Generic Radio component presents a list of questions with three columns for selecting an answer and a space for notes. The notes field uses “answer memory” and will provide a drop-down menu of past notes based on the provider or the patient.

Following is an example of a Generic Radio component, used in an ADHD protocol:

When creating a new Generic Radio component, you must set the three column answers (such as “Yes, No, N/A”), indicate the default selection column, and then create a list of available questions.


When you add a Generic Radio component to a protocol, you must indicate which questions should appear by default on the chart note. You can also indicate whether or not the item has an anchor button for navigation, and you can set whether answer memory should be filtered by provider, patient, or unfiltered.


Create and Edit a Protocol

August 3, 2015/in Get Started Configure Chart Notes and PCC EHR Components Configure Chart Notes and Components /by Douglas Beagley

Follow the steps below to use the Protocol Configuration tool to clone or create a new protocol and add components to that protocol.

By reading this procedure, you can learn how to open the Protocol Builder, and how to add, configure, or remove the components in PCC EHR’s custom chart notes. For a simple example of editing a protocol, read Add Specific Imms to a Protocol. For more information, read the other Protocol Builder help articles.

Check Out Awesome Examples: PCC hosts a web site displaying protocols created by pediatric practices around the country. You can review these award-winning chart notes at protocols.pcc.com.

Open the Protocol Configuration Tool and Log In

For more information, read Open the Protocol Configuration Tool.

Click “Protocol Builder”

Clone or Create a Protocol

You can select an existing protocol and click “Clone” to make a copy for editing. Creating a new protocol from a blank page is a lot of work, so you may find it helpful to clone and then edit.


Copy Auto-Notes: Your practice or an individual clinician can create auto-notes, which make charting faster, easier, and more consistent. When cloning a protocol, you can decide whether to copy existing auto-notes into place or not. If you are not certain, answer “Yes” to this question so that users will have the option of continuing to use existing auto-notes.

Click “Edit”

After cloning or creating a protocol, it will open for editing.

If you are returning to the Protocol Builder to continue working, select your new protocol and click “Edit”.


Add or Delete Components (Optional)

If you cloned an existing protocol, you may have exactly the sections and headers that you need. If you are starting from scratch or want to add a new section, click “Add Components”.


Use the pull down menu to select the component you need, and click “Add”.

What Am I Adding?: Next to each component name is the component type, which can give you some idea of how the component is used. For more information, read Component Reference.

Special Components: In addition to components for orders and entering chart notes, you can add a sibling list, a summary of a patient’s appointments, growth charts, and many other items to chart notes. Read Add Special Components to learn more.

Create a New Component: You can create custom components, with your own sets of questions or text fields, using the Component Builder.

Delete Components: Select any protocol component and click “Delete” to remove it from this protocol.

Rearrange Components (Optional)

You can change the order of your components by click and dragging them.

Configure Components

After adding a component, you should configure the correct title, the list of items or questions, and other options for this specific protocol. Select one of the components in your protocol and click “Edit” to configure that component for the particular chart note protocol.


What can you do while configuring a component in a protocol?

Set Anchor: Any component in a protocol may appear as one of the navigation buttons on the left hand side of the screen while charting. While editing a component, you can indicate that it should have an anchor navigation button.

Change Title: You can edit the title of the component, which also appears as the title of the anchor button, if applicable.

Set Filter for Answer Memory: The “Filter” setting controls which set of past answers (the Provider’s or Patient’s) will appear as pull-down options while charting. In most cases, this should be set to “Provider”. You may wish to change it to “Patient” for patient-specific social history questions.

Add (or Delete) Items: Most components have a list of items within them. The “History” and “Review of Systems” components will have different items in different protocols, and you can add different labs to the Labs component, if you wish. Click “Add Items” and select new items from a drop down list. If you need something that is not available at all, such as a brand new lab or question, first use the Component Builder to edit the component.

For more information about the different settings available for each kind of component, read Component Reference.

Configuring Orders for Billing: Whenever you add or modify a new order in the correct component in the component builder, you should consider whether that order should trigger procedure codes for billing on the electronic encounter form. Read the Billing Configuration help article to learn more.

Save, Preview, Quit, Assign

All changes to your protocol are committed as soon as they are made. Click “Protocol List” to return to the list of protocols, where you can preview your new protocol. Close the window at any time to quit.

Assign Your Protocol: Creating a new protocol does not assign it to appear for a provider or visit reason. You must create and add components to your protocol and then use the Protocol Map tool to determine when it will appear for charting.

Adjust PCC EHR Components with the Component Builder

August 3, 2015/in Configure Chart Notes and PCC EHR Components Configure Chart Notes and Components /by Douglas Beagley

PCC EHR’s chart notes, along with chart sections like the Medical Summary and tools like Patient Check-In, are made up of components. Use the Component Builder, inside the Protocol Configuration tool, to create or edit the different components that make up the protocols in PCC EHR.

You can create custom components to deal with a particular charting needs, with your own wording, and then use the Protocol Builder to add components to relevant chart notes or chart sections. You can also use the Component Builder to modify the details or wording of different components, such as adding a new item to the History or Review of Systems components.

After You Make Changes: When you make changes to a component in the Component Builder, it does not alter the component in historical chart records. Additionally, your changes might not be visible until you add or adjust settings for the component in a protocol. For example, if you add a new available item to the “History” component, it will not automatically appear visibly on chart notes. You must use the Protocol Builder to customize the chart note and indicate that your new History item should appear with that component. You may also need to adjust your Protocol Map to ensure that the correct providers see the desired chart note for each visit reason.

Open the Component Builder

To get started with the Component Builder, open the Protocol Configuration tool from the Configuration menu. Then click “Component Builder”.

The Component Builder window displays the name, the component type, and a column of other configuration notes about the component.

Edit a Component

Select any component and click “Edit” to make changes.


In the above example, a user is editing the “Review of Systems”, a component of type “Generic Radio”. In the edit window, we can specify all the different possible systems that could appear on a chart note. You can add as many items as you wish.

Later, in the Protocol Builder, the user can add the Review of Systems component to any protocol. Then they can specify which of the listed items will appear for that Protocol.

For a complete guide to the different settings for each component, read Component Reference.

Clear/Delete: The two check boxes on the editing list allow you clear all historical answers stored in PCC EHR for an item, or to delete the item from the component. The changes will take place when you click “Save”.

Turn On Last Answer: PCC EHR can display the last charted answer for Generic Check, Q & A, or Generic Text style components. You can activate or deactivate this feature while editing the component.

Edit an Order Component

When you edit an order component, such as the Referral Orders component or the Medical Procedure Orders component, you can add new orders and set various default behaviors.



For each order, you can set default behaviors and add LOINC tests. You can also add SNOMED-CT procedures for reporting.

After you add or edit an order, use the Protocol Builder to make the component and the desired order appear on specific chart notes.

Labs and Immunizations are Different than Other Orders: You can create and edit most kinds of orders in the Component Builder. You must create and edit lab orders in the Lab Configuration the Lab Configuration Tool, and new immunizations have additional configuration requirements, many of which PCC Support can complete for you.

Configuring Orders for Billing: Whenever you add or modify a new order in the correct component in the component builder, you should consider whether that order should trigger procedure codes for billing on the electronic encounter form. Read the Billing Configuration help article to learn more.

Create a New Component

Click “Add” to create a new component.


Don't Make Duplicate Components: When you edit a component, you edit all possible items that might appear in that component… later, in the Protocol Configuration tool, you can set which items appear. Therefore you only need one “History” component, for example, to which you can add all the available history questions for all ages, all patients, and all chart notes. Later, in the Protocol Builder, you can determine which history questions will appear for each protocol.

Enter a name for your new component and then select a component type. After selecting a component type, the component builder will ask you questions specific to that type of component. For example, in the Generic Radio component above, the user indicates what the three column choices will be and which choice will be the default.

For a complete guide to the different component types, read Component Reference.

Add Items to an Existing Component vs. Creating a New Component: You should not create a new component when you need different sorts of questions or orders for an existing component. For example, you can add all possible History or Review of Systems questions to the original component, and then use the Protocol Builder to configure which questions should appear in each chart note protocol. Similarly, you can create a new order inside the Referrals or Medical Procedure component, create new labs in the Lab Configuration Tool, and then use the Protocol Builder to determine which of those orders appear for each chart note.

PCC EHR Help

August 3, 2015/in Get Started in PCC EHR Get Started in PCC EHR /by Douglas Beagley

You can access PCC EHR’s online Help system directly, while logged in.

Click on the Help menu and select PCC EHR Help for a table of contents, Index of Topics for an index, and Search to open the help search screen.

You can also contact PCC Support for additional assistance at 802-846-8177 or 800-722-7708 or support@pcc.com.

Signing Documents

August 3, 2015/in Review and Sign Chart Notes, Orders and Documents Review and Sign Chart Notes, Orders and Documents /by Douglas Beagley

You can mark any document to indicate that it needs review and signing by a clinician. Select the clinician from the right panel of the Import Documents screen.

Alternatively, you can click “Edit” while viewing any Document in a patient’s chart and mark an item as requiring a signature.

A document that needs to be signed will appear on the Signing queue.

Double-click an item to review and sign it using the Sign Item pop-up window.

Optional: Before signing, you can jump into the chart to review the situation or make changes.

Signing Permissions: Only users with Signing access permissions may sign charts, documents, or other items.

Patient Population Dashboard

August 3, 2015/in Review Practice Benchmarks Dashboard Pediatric Benchmarks For Your Practice /by Douglas Beagley

The Patient Population dashboard displays a dynamic age distribution graph.


Use the graph to track your age distribution over time, as a practice or for a single provider. The box at the left presents your current total, and the graph on the right allows you to track your age distribution over time. You can select a single provider or all providers, and optionally limit by age range.

Review Individual Dashboard Measures

August 3, 2015/in Review Practice Benchmarks Dashboard Pediatric Benchmarks For Your Practice /by Douglas Beagley

Click on any dashboard measure from your Practice Vitals Dashboard to see more details.


You’ll see an explanation of your score, comparison charts, trends, and recommendations.

From the top of each details page, you can use a pull-down menu to navigate to any other measure.

Most measures include the following sections:

  • Your Score, and Definition: Your score, and how that score is calculated.

  • How You Compare: Your averages compared to other PCC clients.

  • PCC Client Distribution: A distribution graph showing where your numbers are in context with other practices.

  • Trend: A history of your data over time.

  • Recommendations: What you can do to increase your score.

  • Related Tools: A list of links to other measures, patient lists, or reports that break the data down by provider or by vulnerable populations.

Detailed Breakdown

Scroll to the bottom of a measure and click on a Related Tools link to view a breakdown of the data.

After clicking on a link to review a breakdown of the data, you can sometimes select additional breakdown criteria.

You can use this data to review measure results for each primary care physician, or review how your practice meets the measure for variety of vulnerable populations.

For example, you could review a Provider breakdown on the Sick-to-Well Visit Ratio measure.

The Provider Breakdown of the Sick-to-Well Ratio compares visit ratio for providers at your practice. You can use the Compare section to generate a bar chart for a specific provider.

Work With Merck: Another example use of the Detailed Breakdown tool is in the Immunization Rates – HPV measure. You can use the Age and Sex Breakdown Report to provide the necessary data for Merck’s “Health In Focus” rebate program.

Productivity Dashboard

August 3, 2015/in Review Practice Benchmarks Dashboard Pediatric Benchmarks For Your Practice /by Douglas Beagley

The Productivity Dashboard reports on visits and RVU totals, per provider or per location. You can track visit trends over time, and examine activity for a specific physician.

Set the Productivity Measure at the top of the screen. You can measure all visits, well or sick visits, or RVUs. Next, select a single or multiple providers and locations. Then enter a month or year-to-date range and click “Generate Graph”.

Read Report on Productivity the Report Library to learn how to use the Report Library for specific productivity reporting.

Use a Patient Care Plan to Improve Care for Chronic Patient Issues

August 3, 2015/in Review a Patient's Chart Review a Patient's Chart /by Douglas Beagley

Use the Care Plan component, available on the Medical Summary or other protocols in PCC EHR, to track, coordinate, and print the management plan for chronic patient issues.

The chart-wide Care Plan component can store all of a patient’s care plan information in a clear, structured format that you can review and update from the Medical Summary or on any chart note.

Review Interventions in a Care Plan

A patient’s care plan can be made up of one or more different interventions. While reviewing the care plan summary, click the arrow to see more details about a particular intervention. For example, you can review and edit a patient’s Asthma Action Plan.


Each intervention can have Goals, Actions, Next Steps, Care Coordination Notes for internal use, and one or more Team Members. A patient can have more than one intervention in their overall care plan, so they may have an asthma action plan, a diabetes management intervention, and so forth.

Each intervention can have a status of Active, Inactive, or Resolved. You can set the status and then filter which interventions appear, just as you can with problems on the Problem List.

Create an Intervention in a Care Plan

While in Edit mode, click “Add Intervention” to create a new intervention.


Goals can be any text, and each item will appear as a bulleted point. Actions draw from a SNOMED list of therapies. Next Steps and Care Coordination Notes can be any text. Team Members draw from the list described below.

Care Plans and Standards: Care plans are a requirement for PCMH and are recommended by some payers. The Care Plan component is chart wide, making it ideal for tracking any chronic issue. You can use it to meet the NCQA guidelines for meeting the requirements of PCMH.

Who are the Intervention Team Members?

Care plan interventions may have one or more Team Members. Click on the down arrow to see a list of available members. You can add a new patient contact, or select from the patient’s custodian, guarantor, or My Kid’s Chart portal users. You can also choose from a list of your practice’s professional contacts.

For more information about professional contacts, read the Professional Contact Manager article.

After selecting a team member, you can add a note. For example, you can describe their role for the intervention.

Attach Documents to a Care Plan Intervention

You can attach a document to a patient’s care plan intervention. Each of a patient’s interventions will appear in the Import Documents window as well as in the Edit Tags window in the Documents section of a patient’s chart.

After adding a document to an intervention, it will available for review in the Care Plan component.

Print the Patient Care Plan

Click “Print” to print out a patient’s Care Plan. You can print the care plan at any time, you do not need a specific visit date.

When you print, you can choose whether to include only Active interventions, and select other options.



Where Does the Care Plan Appear?

The Care Plan component appears on the Medical Summary screen by default. Your practice can use the Protocol Configuration Tool to move or remove it, or add it to any chart note protocol.

When the Care Plan component appears on chart notes, you can review interventions by clicking “Mark as Reviewed” and they will be copied into the chart note and appear in the patient’s Visit History.

Review and Sign Visits, Orders, and Other Items in PCC EHR

August 3, 2015/in Get Started Review and Sign Chart Notes, Orders and Documents Review and Sign Chart Notes, Orders and Documents /by Douglas Beagley

The signing queue contains a list of items that require a clinician’s review and signature.

Your clinicians can use the Signing queue to review, sign and co-sign visit chart notes, phone notes, lab results, or scanned documents.


To sign an item, simply double-click it, review, and then click “Sign”:



The Visit History in each patient’s chart maintains a record of who signed each item.

Signing Optional: PCC EHR automatically expects a signature for visit chart notes and lab results sent electronically to PCC EHR from a lab vendor. All other items may be set to require a signature or not by the user. For example, not all imported documents or phone notes need a physician’s acknowledgement. Read the sections below to learn how this works.

Changing a Chart Note After Signing: Providers may continue to open the chart notes and make changes after it has been signed. A chart can be signed multiple times, by multiple people. PCC EHR tracks who signed a note and when it was signed. You can review the signed status in the header of the chart note.

Signing Permissions: Only users with “Signing” access permissions may sign charts, documents, or other items.

Signing Status on the Schedule Screen: You can also see what visits need to be signed right on the schedule screen by looking at the “Signed” column. This column is blank for unsigned visits. If a visit has been signed, the names of all signers will appear here. Visits that need to be co-signed display the required co-signer’s name in orange. Note that this only indicates the signing status of the visit; you must use the Signing Queue to find orders and other items that need signing.

Confidential Notes and Other Confidential Fields

August 3, 2015/in Medical Summary Component Reference Medical Summary Component Reference /by Douglas Beagley

Use the Confidential Information section on the Medical Summary screen to note private patient issues that should be hidden during casual chart review.

Click the expanding triangle to review confidential information.


Click “Edit” to make changes.


Access Log: PCC EHR logs every time a user accesses or edits a patient’s Confidential Notes. This information is kept in the database, so if you need a log of every user who has reviewed a patient’s confidential notes, contact PCC Support.

No Saved Notes, Modification Date: You will see the “No Saved Notes” text next to the section header if the section is blank. If any notes have been entered, you will see the “Modified” date, letting you know that there is confidential information stored in the field and when it was last edited.

Other Confidential Fields: The confidential toggle arrow is an option for any Medical Summary note field. You can turn on the confidential feature using the Medical Summary Builder inside the Protocol Configuration tool in the Tools menu.

Confidential Notes are Not Patient-Facing: Information stored in the Confidential Notes component will not print out on any reports, including the Health Information Summary, Patient Visit Summary, or the Summary of Care Record. It will not appear anywhere in the patient portal.

For more information about patient privacy and making certain items confidential, read the Patient Privacy Features article.

Family Medical History

August 3, 2015/in Medical Summary Component Reference Medical Summary Component Reference /by Douglas Beagley

Use the Family Medical History component to chart medical history for family members.

The component can appear on the Medical Summary, in the Demographics section of the chart, within the Patient Check-In ribbon, and on any chart note.

In edit mode, click on a blank field to add a new condition and relationship.

For each condition, you can select a diagnosis from your practice’s Family History list, or right-click to search the SNOMED diagnosis list. Next, you can indicate one or more family members who have the diagnosis, and enter notes. The relationship field comes from a standardized HL7 list of relationships.

What is Your Practice’s Family History Diagnosis List?

Instead of picking from all 10,000 available diagnoses, PCC EHR includes a customizable Family History list of SNOMED descriptions. Any diagnosis you use in the Family Medical History component becomes part of your Family History diagnosis list. You can right-click on the field and search the entire SNOMED diagnosis list to find other diagnoses.

PCC adds a default starter list of common diagnoses that an office might want to track for family history. You can customize the list in the Diagnosis Configuration tool.

Read the Diagnosis Configuration Tool help article to learn more.

Copy Family Medical History to Siblings

You can copy a patient’s Family Medical History to siblings. While reviewing a patient either right click on the component or select Copy Notes to Siblings from the Edit menu.

Next, select the type of notes to copy and click Next.

Finally, select whether the history for the open patient chart will Append or Replace the sibling’s history. You can also choose to customize what is copied, or skip the sibling.

You might choose to customize the result to avoid copying information about the sibling. In the above example, the user removed “Brother” for the Heart Disease condition, as Dino is the brother referenced in Pebble’s Family Medical History.

Click Save to save your changes and import the history into the sibling’s chart. If the patient has multiple siblings, PCC EHR will present a new choice for each sibling.

Where Does Family Medical History Appear?

The Family Medical History component appears on the Medical Summary by default. You can move or remove it, or add it to any chart note protocol.

When the Family Medical History component appears on chart notes, you can review it by clicking “Mark as Reviewed” and the information will be copied into the chart note and appear in the patient’s Visit History.

The Other Family History Component

Your practice may also use the Family History component on your Medical Summary and/or on chart note protocols. Family History is a chart wide note field that stores unstructured notes about family history.

You can use either component or both, and use the Protocol Configuration Tool to choose where each component appears..

History and Custom Note Fields

August 3, 2015/in Medical Summary Component Reference Medical Summary Component Reference /by Douglas Beagley

The Medical, Family, and Social History components store and display relevant patient history. These chart-wide components can appear on the Medical Summary, Phone Notes, or any chart note protocol.

Your practice can create additional custom note fields for other purposes.

Expanding: Each note section of the Medical Summary screen expands as you enter more information.

Click “Edit” to make changes.


After making changes on the Medical Summary, you can copy or append the changes to any of the patient’s siblings. Read the Medical Summary overview to learn how.

Problem List

August 3, 2015/in Medical Summary Component Reference Medical Summary Component Reference /by Douglas Beagley

The patient Problem List is a list of patient issues. These items can be based on any diagnosis. The Problem List appears on a patient’s Medical Summary by default, but can be added to any chart note protocol. You can add or remove problems, and rearrange problems. The Problem List makes prominent patient issues clear to anyone who opens the chart.

Review a Problem List

Each problem includes a diagnosis description (from SNOMED-CT, or ICD-9 for pre-2014 Problems) and a Resolved/Active/Inactive status. There are also optional fields for Problem Note, Onset date, and Resolved date.

Sensitive Diagnoses: Diagnoses on the problem list that are sensitive are indicated with a red lock. These diagnoses will not appear on the patient portal or on printed patient-facing materials and reports. For more on how to configure sensitive diagnoses, click here.

If you wish to view active, inactive, and/or resolved problems, you can use the Display filter menu to change which problem statuses should be visible. PCC EHR will remember your preferences across all charts.

Click “Edit” to make changes to the Problem List.

Add a Problem

You can add a problem while charting the diagnosis during a visit.

You can also add a problem on the Medical Summary screen. Click in a blank field to add a new problem. You can type a few letters and PCC EHR will search through your practice’s Favorites list.

Can't Find a Problem?: The list of available problems comes from a subset of the SNOMED-CT library. You can right-click on the field to search the entire SNOMED-CT library of diagnosis descriptions.

Set a Status

Click on the drop-down menu to set the status of any problem.

Problems can be Active, Inactive, or Resolved.

Toggle Sensitive Diagnoses

Click on the lock icons to indicate whether or not it will appear on patient-facing reports and in the portal.

For more information on using and configuring sensitive diagnoses, click here.

Indicate “No Known Problems”

You can select “No Known Problems” from the drop-down list of problems in order to indicate you have reviewed the patient’s history and are maintaining a problem list for them.

Using this indicator is recommended, especially if you are attempting to meet Meaningful Use requirements or wish to apply for the ARRA incentive. Leaving the Problem List blank is not the same as indicating “No Known Problems”.

Rearrange Problems

Click the button tab and drag a problem to rearrange your problem list.

Remove a Problem

Select any problem and erase the problem field to remove it from the patient’s problem list.

Alternatively, you can right-click on a problem and select “Delete Problem from the contextual menu”:

After removing a problem, click “Save” to save your changes.

Problem List Entries, Code Set and Terminology Updates, and ICD-9

Every six months, the SNOMED library of clinical terms updates. The update sometimes revises the text descriptions for diagnoses. When this happens, PCC preserves the original text description as entered in a chart note, showing the historical diagnosis as chosen by the physician. The patient’s Problem List, however, will display the newest and most up-to-date text description for a given diagnosis.

If a diagnosis is removed or deprecated from SNOMED, PCC will preserve the deprecated item on the Problem List for the patient.

PCC EHR’s chosen diagnosis terminology switched from ICD-9 to SNOMED-CT in 2014. However, the patient’s Problem List may continue to display historical ICD-9 diagnosis descriptions. It is not possible to add an ICD-9 diagnosis to a patient’s Problem List.

Down Syndrome Features and the Problem List

If a patient has a Down syndrome (Trisomy 21) diagnosis on their Problem List, PCC EHR will automatically display Down syndrome growth charts for the patient and will display all of their vitals percentiles based on Down syndrome growth chart data.

You can learn how to configure these options in the Configure Growth Charts article.

EDI Dashboard

August 3, 2015/in Review Practice Benchmarks Dashboard Pediatric Benchmarks For Your Practice /by Douglas Beagley

The EDI Dashboard shows you detailed totals for your practice’s claim activity. You can see total claims, amount billed, and amount rejected or accepted by the claim clearinghouse and payor. You can use the EDI Dashboard to evaluate your claim volume (for both electronic and paper claims) and rejection rates for individual payers.

Set the time period at the top of the screen and click “Go” to recalculate each of the sections.

The Medical Summary

August 3, 2015/in Review a Patient's Chart Review a Patient's Chart /by Douglas Beagley

When you open a chart, the Medical Summary is the first screen. It contains a configurable summary of patient information.

What Appears on the Medical Summary?

Your office can decide which components appear on the Medical Summary. The default components include:

  • Recent and Upcoming Appointments
  • Reminders
  • Problem List
  • Problem List from PCC eRx
  • Care Plan
  • Family Medical History
  • Siblings
  • Medication History
  • Medical and Social History notes
  • Confidential Information
  • Allergy Lists (both general and Medication related lists)

Custom Components: In addition to these default components that ship with PCC EHR, your office can create custom Medical Summary components to story other chart-wide information, such as Care Plan Notes or Hospitalization Notes.

Reusable Components: Medical Summary components can also appear right on your chart notes, for easy access while charting. The information is chart-wide, however, and not part of any single visit.

Configuration: Read the Configure the Medical Summary article to learn how to change the layout and content of your practice’s Medical Summary chart section.

Navigation

While working anywhere in the patient chart, you can return to the Medical Summary screen at any time by clicking on the top navigation button.

Use the Medical Summary navigation buttons to jump directly to a specific section.

Configurable: The Medical Summary anchor buttons are configurable. Your office can decide which items need a navigation button and customize the button text.

Make Changes

Click Edit to make changes and enter notes and history in Medical Summary components.


While you are in Edit mode, you can click a navigation button to place your cursor directly into the desired field or section.

Make Changes Elsewhere in the Chart

Some items in the Medical Summary change based on activity in the chart or in other chart sections. For example, the Medication History draws from the patient’s Prescriptions section, and users can add diagnoses to the Problem List on-the-fly while charting diagnoses in a visit.

Medical Summary components can be added to chart notes, so users can edit any of these items while charting, as well.

Search the Medical Summary

If your practice stores a lot of patient information on the Medical Summary, you may want to search for specific text. You can select Find from the Edit menu or use your operating system’s keyboard shortcuts to find text and cycle through multiple found results. For more information, read the Search a Chart Note or Protocol-Based Chart Note help article.

Copy Notes to Siblings

Medical Summary note components, like the Reminders, Social/Family/Medical History, and Confidential Notes, may contain information that should be added to a sibling’s chart as well.

When you want to copy a note field to a sibling, right-click on the note and select Copy (Component Name) to Siblings.


A window will help you append, replace, or customize what will be copied to the sibling. You can review exactly what the sibling’s new note will be. Use the “Custom” option if you want to make changes.

After selecting “Custom”, you can revise the resulting note and use your mouse and your computer’s copy and paste commands to adjust the text.

Smart Copy: PCC EHR will save you time by ignoring identical text between siblings. For example, if both siblings already have exactly the same text at the beginning of a Family History note, PCC EHR will only prompt you to copy the new text to the sibling. The copying process will skip the part they already have in common.

Edit Menu: Instead of right-clicking on the note field you wish to copy to siblings, you can also select “Copy Medical Summary Notes to Siblings” from the Edit menu and then choose which note to copy.


Only Medical Summary notes that contain text will appear on the drop-down menu. If the patient only has one note, such as “Reminders”, PCC EHR will automatically select that one for you

Read below to learn more about each section of the Medical Summary screen.

Sign Orders

August 3, 2015/in Review and Sign Chart Notes, Orders and Documents Review and Sign Chart Notes, Orders and Documents /by Douglas Beagley

You can mark any order, such as a lab or medical procedure, to indicate that a signature is required. You may do this for actual signing purposes, or simply to indicate that a clinician needs to review some aspect of the order.

Later, a clinician can find the order on the Signing queue, review details, add notes, create follow up tasks, and sign the order.

What Orders Appear on the Signing Queue?

Click “Edit” next to any order to review whether it requires a signature. You can do this on the chart note itself, or in an Edit Orders dialog from the Schedule or the Visit Tasks queue.

Click on “Signature Required” to change the status. PCC EHR will remember whether you require a signature for each type of order, and set the value for you the next time you create the same kind of order.

E-Labs Always Require a Signature: Physicians use the Signing queue to review incoming lab results that were sent directly from a lab vendor to PCC EHR. Therefore e-lab results always require a signature.

Review Orders on the Signing Queue

Orders that require a signature appear on the Signing queue.

Double-click on any item to review details, add notes, and sign it.

On the Sign Orders window, a clinician can:

  • review results,
  • enter a signing note for each lab order,
  • click “Open Chart” to review the patient’s entire record,
  • create an Order Follow-up phone task

When the clinician finishes taking action on the order, they can save and exit without signing the orders, or they can click Sign to finish their work.

Signing Permissions: Only users with “Signing” access permissions may sign charts, documents, or other items.

Complete Order Follow-up Tasks

If a physician creates a task on an order in the Sign Orders window, the nurse or other clinician will find it on the Messaging queue along with phone notes and other messages. They can double-click to open up the Order Follow-Up task.


Just like phone notes, an Orders Follow-up note is a customizable ribbon. By default, it contains the lab test results and all the information needed to call the patient or family, discuss the results, or perform other actions related to the order.

Order Follow-up notes also appear in the patient’s Visit History, for later review.

Sign Phone Notes

August 3, 2015/in Review and Sign Chart Notes, Orders and Documents Review and Sign Chart Notes, Orders and Documents /by Douglas Beagley

You can mark any phone note to indicate that it needs signing. Select the provider from the Phone Note screen.

A phone note that needs to be signed will appear on the Signing queue.

Double-click on a phone note to review and sign it, using the Sign Item pop-up window.

Optional: Before signing, you can jump into the chart to review the situation or make changes.

Signing Permissions: Only users with “Signing” access permissions may sign charts, documents, or other items.

Review and Update Patient and Family Demographics

August 3, 2015/in Get Started Edit Patient and Family Information Edit Patient and Family Information /by Douglas Beagley

Use the Demographics section of a patient’s chart to review and edit patient and family demographics, such as patient information, contact information, insurance policies, and siblings.

Review Demographics

Click the Demographics button inside any patient’s chart to review their demographic information.


You can review and update patient status flags, update communication preferences, edit or re-assign family accounts, and perform other actions. The Demographics screen displays the primary care physician and (optionally) your practice’s customizable data fields.

The Demographics section of the patient’s chart is a configurable ribbon. You can navigate up and down the ribbon by using the anchor buttons on the side menu.

You can use the PCC EHR Configuration Tool to add or remove components to customize the section layout.

Edit Patient Demographics

Click “Edit” to make changes to the patient’s demographics.


Click in any editable field to enter a new value. For Preferred Language, and other fields with known values, you can begin typing to perform a search.

Some fields, like patient and account status flags, use pull-down menus that allow multiple selections.

Here are some tips about specific demographics fields:

  • Preferred Language Tips: PCC EHR will track your language frequency and indicate your office’s top ten languages when you click on the field. Note that you can click the plus sign to indicate the patient has more than one preferred language.

  • Use Zip +4: If your practice bills for home visits, remember to add the complete “Zip +4” Zip Code, as insurance carriers usually require all nine digits.

  • Relation to Bill Payer and Relationship to Subscriber: When PCC processes claims, it uses the relationship to subscriber entered for the patient’s specific policy first. If blank, PCC looks at the “Relation to Bill Payer” entered in the patient’s demographics record.

  • Use Only Numeric Digits in Phone Number Fields: When entering phone numbers, use only the complete 10-digit phone number. Avoid adding text characters or notes to a phone number field. If your practice wants to track cell phone vs. landline, or multiple phone numbers for different adults on an account (for example), you can do so by working with PCC Support to relabel the custom phone number fields or by using the Personal Contacts component, described below. Most contact tools (like Broadcast Messaging, and other tools provided by PCC and third-party vendors) will strip any extra text from a phone number field, but some may not. PCC has noticed that state immunization registries and other types of reporting that require phone numbers can fail if phone number fields include additional information. If your practice’s workflow requires text in the phone number field, always ensure that it appears after the number and not before, as that can prevent some common issues.

When you are finished editing demographics, click “Save” to save your changes and return to view mode.

Update a Patient’s Race, Ethnicity, and Language

Options in the Ethnicity, Race, and Preferred Language fields are limited to standardized national lists. You may not enter a custom race, for example. If you require a race or ethnicity that is not listed for your practice, contact PCC Support at 802-846-8177 or 800-722-7708.

Read Add Additional Races, Ethnicities, and Languages in PCC EHR to learn more.

Change a Patient’s Home or Billing Account

You can change the Home (Custodian) and Billing (Guarantor) account(s) for a patient, or add another account, if the family needs separate Home and Billing accounts.

While you are in editing mode in the Demographics screen, click the “Reassign Account” button next to the currently associated account.

Search for the account. If the account does not already exist, you can click “Create Account”.

Next, select whether the account is home, billing, or both.

Link Patient Portal Accounts

You can link patient portal accounts to your patients’ Home and Billing Accounts. With EHR accounts linked to portal accounts, you can be sure you’re getting information from the correct source.

Connect an Existing Portal User

If there are one or more patient portal accounts already connected to this patient, the Add button will open a window where you can either select from the existing users connected to this patient, or create a new user for this PCC EHR account.



Selecting an existing user and clicking Continue will link the selected pre-existing user to the account.

 

Review and Update Account Notes

To review and update account notes, visit the Payments tool in PCC EHR.

Read the Account Notes section of the Post Payments article to learn more, or watch the Post Payments video.

Communication Preferences

By default, PCC EHR believes a patient’s primary contact information is determined by their custodian (home) account. You can enter a different contact preference by clicking “Edit” and filling out one or more of the fields for confidential communication preference.

You can record and store information for all fields. Select one field with the toggle button to indicate the patient’s preference. Click “Save” to save your changes. Patient Reminders and the Patient Notification Center both use the patient’s confidential communication preference.

Immunization Registry Communication Preferences

Does your practice have permission to send patient immunization information to a registry? And how should an immunization registry contact a family? These questions may seem obvious: of course, and, why would they need to?

The “Immunization Registry Communication Preferences” appear in the Patient Contact component.

Your Immunization Registry may require that you answer these questions for each patient.

Usually, a practice includes permission for immunization registry submission in their standard paperwork, making it safe to answer that question with a “Yes”. Otherwise, your practice should confirm permission with the patient’s guardian.

Preferred Contact Method: Some registries (such as CAIR in California) state that the “Preferred Contact Method” field must be sent to the registry if it is collected, but the field may be empty. From past experience with immunization registries, PCC recommends that all practices, regardless of state, fill this field with the patient or family’s contact preferences for information related to immunization registries. For example, if the family does not wish to be contacted, select “No Reminders and No Recalls”.

For more information, read Submit Immunization Records to Registries.

View Siblings

Click “Open Chart” next to a sibling to open their chart as well. For more information on working with multiple sibling charts, read the Review and Edit Sibling Charts help article.

Deceased Patients in the Patient Chart

You can indicate if a patient is deceased in the Demographics chart section.


Users will see when a patient is deceased at the top of the chart. Instead of the patient’s calculated age, the word “deceased” appears. Reports, queues, and patient search results will also display that the patient is deceased.

Optional Fields

The Patient Demographics component includes optional fields for birth order and the mother’s full maiden name. You can use the Component Builder inside the Protocol Configuration tool to turn these features on or off.

The component can also include other optional patient identifiers, such as driver’s license number or medical ID numbers.

Use the Component Builder to adjust the settings for the Patient Demographics component.

Policies Component

By default, the Policies component appears in the Demographics section of the patient’s chart. The Policies component might also appear on chart notes, phone notes, checkin, or other protocols in PCC EHR.

To learn how to review and update patient policies, read Update Patient Insurance Policies.

Personal Contacts Component

The Personal Contacts component is an optional chart-wide component that appears on the Demographics section of the chart by default. It can store a patient’s parents, guardians, or other relations.

You can move, remove, or add the component to any chart note protocol, the Medical Summary, or your Phone Notes protocol.

In edit mode, you can add a contact, or add a note, edit, or remove a contact.

Click on the blank pull-down field and to add a new personal contact. You can select “Add Patient Contact” to create a new contact, or select from the patient’s connected practice management accounts (Custodian, Guarantor) or MyKidsChart.com user accounts.

The First and Last name and Relationship fields are required for each personal contact.

Next of Kin: The Personal Contacts component is designed to work as the “Next of Kin or Associated Parties” segment of the HL7 standard and is a requirement for some state immunization registries.

Automatically Add the Custodian: If you want every new patient’s custodian to be added as a contact automatically, you can turn that feature on in Practice Preferences.

Work with Documents in a Patient’s Chart

August 3, 2015/in Review a Patient's Chart Review a Patient's Chart /by Douglas Beagley

Find and work with patient documents in the Documents section of the patient’s chart. The Documents section of a patient’s chart displays all documents associated with the patient, sorted by category and date.

Find Patient and Account Documents

Open the patient’s chart. Click on “History” in the navigation, then select “Documents” to view the patient’s document categories.

  • Patient documents are generally directed to the family, school, or specialists. These might include excuse forms, asthma action plans, referral forms, etc.
  • Account documents are directed to the account holder (the guarantor or custodian). These are usually billing- or insurance-related forms such as past due letters, address verification letters, or policy-related mailings.

Click the arrow next to a category to expand and show documents in that category. If an arrow is orange, the document includes at least one outstanding task.

For each document, you can see a thumbnail of the image, any notes or tags attached to the document, and if it is related to a specific encounter. You can see whether the document was shared in the portal, if it is awaiting a signature, and any associated tasks.

Sorted By Category and Date: Documents in a patient’s chart are first sorted by your practice’s custom list of categories, and then by document date. A document’s date is based on the order or visit it is attached to. If a document is unattached, you can enter a manual unattached date by editing the document’s tags.

Print Scanned Documents

Select any document on the Documents screen and click “Print” to print a copy.

You can also print documents with their notes, print only the notes, or print the document by itself. Select a document and click on the File menu to see your printing options.

View and Edit Documents

Double-click on any document on the Documents screen to view it.

You can also find documents on the Visit History screen and click “View Documents” to view them.

While viewing a document, use the Rotate, Fit Width, -, +, and Zoom to Fit buttons to adjust your document view.

Click “Edit” to access the Document Tags.

You can edit various document tags and attributes. You can also remove the document from a patient’s chart using the Remove Document button, or if a provider is viewing the document, they can sign it right from this screen.

You can make several changes to the document:

  • Rotate: Click “Rotate Document” to change the default rotation of the document in all views.

  • Title: The document Title is used to identify the document in the Visit History and Documents section of the patient history, as well as in My Kid’s Chart, the patient portal.

  • Category: Choose a new Category, such as Correspondence or Radiology, to reclassify the document. If you wish to edit the document categories your office uses, read Edit Document Categories.

  • Attach Document: To associate a document with a visit or other chart event, click “Attach Document” and select from the drop-down menu. If selecting a visit, you can then optionally select an order or orders within that visit. Or, file as an unattached document.

  • Signing: If the document needs to be signed by a provider, you can choose that provider here.

  • Patient Portal: Check this box to share the document with My Kid’s Chart accounts that have access to this patient’s records.

  • Notes: Enter notes about the document and they will appear in both the Visit History and on the Documents screen.

  • Remove: Click “Remove Document” to remove the document from this patient. You can then use the Import Documents screen to link the document to another patient.

For a more detailed explanation of each of these document tags, read more about importing documents into a patient’s chart.

Work With Document Tasks

You can use the Tasks tool to add and complete tasks while editing a document in PCC EHR.

Create a Task

You can create a task while a document is in “Edit” mode.

The Tasks tool is located just beneath the Document Tags. You may need to scroll down to see them.

For each document you can add new tasks, select a user, and add a note. You can add more than one task if many different users need to respond to the content of a document.

Click “Add Task” to add as many tasks as you need to the document.

Complete a Task

Users can review and work with document tasks on the Messaging queue in PCC EHR.


When they open a document, they can see contact information which will help them complete many tasks. For example, if you needed to call back a patient’s mom about a document, the contact information would be ready for you.

Sign a Document

If you review a document while working in the patient’s chart, you can sign it from there. You do not need to visit the Signing queue to pick up and sign the document.


Flowsheets

August 3, 2015/in Review a Patient's Chart Review a Patient's Chart /by Douglas Beagley

Use the Flowsheets section of the patient’s chart to review historical diagnoses, completed labs, medical tests, screenings, and radiology, and vitals. For example, you can see the results of every time a patient had a specific lab test.


Review a Flowsheet

Follow these steps when you wish to review the history of a patient’s diagnoses, any lab, medical test, radiology, or screening, or vitals.

Open a Chart and Click “Flowsheets”

Click the Tab of the Category You Wish to Review

Scroll Down to Find an Order, Test or Other Item

Scroll to the Right to Review Matching Historical Items

Optional: Use Display Filters and Other Tools to Refine Your View

As you review a complex flowsheet, you can use a display filter to focus in on one or more items that you need to review.

For the Vitals flowsheet, you can also change the grid to display a single column for each date of service.

Sample Flowsheet Details

Each cell on a flowsheet represents a single test, order, or other item.

Here is a sample cell from the Lab flowsheet:

The cell displays all required results for a test, along with any notes. If a test result was marked as abnormal, or it was outside the defined normal guidelines, it will appear in bold text. Note that the date will be the time of service, by default, or the lab specimen collection date, if available.

Get More Details: You can find out more about a specific order or test by noting the date and reviewing the complete chart note in the Visit History section of the chart. For lab tests that occurred as part of an order, you can click on the order name to review all available order details.

Use a Filter to See Only What You Need

Use the “Display” pull-down menu to display only the tests and screenings you wish to review. You can change what appears on the screen to just a few, specific items. You can also use the filter menu to jump directly to one item you wish to review.

As you make your selections, the Flowsheet will dynamically change to display just the items you select. An “All” selection at the top resets the screen to display all items.

Flowsheet Organization Reference

How are items in a flowsheet organized and sorted?

The Flowsheet section of a patient’s chart is split into six tabbed sheets: Diagnoses, Lab, Medical Test, Radiology, Screening and Vitals.

Within each tab, the most recently ordered (and completed) items appear at the top of the flowsheet. So, if a patient had a strep test completed today, their entire history of strep tests will be at the top of the Lab tab of the Flowsheets section of the chart.

A urinalysis or CBC lab contains many different tests, so the Flowsheet will group those tests together for convenience. Tests that are part of a single lab order, or other tests ordered simultaneously with a Snap Lab, will appear together alphabetically.

From left to right, flowsheets extend back in time, showing each historical occurrence of the test or other item. For the Vitals flowsheet, for example, each row displays every historical measurement (or plotted data point) for a particular type of vital.

PCC EHR doesn’t insert blank boxes. Instead, items slide to the left for easier review. If a patient has only ever had one hearing screening, years ago, it will still appear in the left-most column, even though they have had other screenings multiple times that may stretch off to the right. The columns on a flowsheet do not represent a fixed date, they represent all recorded occurrences of the lab or test. On the Vitals flowsheet, however, a “Date Columns” option allows you to rearrange the cells so that each column represents a single date of service.

Only completed items appear on flowsheets. Labs that are ordered but not yet completed, for example, will not appear until all required results are entered and saved.

Review Test Results Over Time

The “Lab Orders” tab displays the result of each test within an order, so you can easily compare results over time for lab tests that are commonly ordered together.

Tests are grouped by LOINC codes, so in-house tests appear in the same row as matching vendor tests. Click the blue lab order name at the top of the column to open the order details.  Use the drop-down menu on the upper right to filter the order list.

Results that are outside of the reference range appear in red text. Hovering the mouse pointer over the result will show the reference range, so you can find all the data you need without leaving the flowsheet. Likewise, hover over the date to see if it represents an Order Date or a Specimen Collection Date. Generic in-house lab orders without an associated LOINC code cannot be linked to elabs or discrete in-house orders. Confidential orders are marked with a red lock icon, and hovering your mouse pointer over the lock shows “Not Released to Patient”.

Use the Diagnosis Flowsheet to Look Up ICD-10 Codes for Patient Diagnoses

If you are filling out a form or need the ICD-10 code for a patient’s diagnosis, you can use the Diagnosis Flowsheet in a patient’s chart to quickly get the codes you need.

For more information, read the Look Up ICD-10 Codes for Referrals, DME, Requisitions, and Pre-Authorizations article.

Understanding Missing Items and Item Categories

Circumstances that may make it difficult to locate some labs, tests, or diagnoses on your flowsheets.

ICD-10 vs. ICD-9

The Diagnosis Flowsheet displays all patient diagnoses, either charted during a visit or found on the patient Problem List. As you review the history of a chronic diagnosis, you may notice a shift depending on whether an ICD-9 or SNOMED-CT description were used for the diagnosis. For example, different diagnoses for the same illness may appear on different lines because the codes do not match.

Tests and Labs Classified and Configured Differently

The Flowsheets section of the chart displays diagnostic test result histories. Flowsheets do not display medical procedures. If your PCC EHR configuration classifies hearing tests or other orders as medical procedures, they will not appear on your flowsheets.

Additionally, you may have some labs or screenings classified as Medical Tests, for example, and they could appear on a different flowsheet tab. PCC Support can help you reclassify diagnostic orders as Labs, Medical Tests, Radiology and Screening so that they appear on the desired flowsheet. PCC can also migrate order history to aide in classification.

Two Rows for the Same Test

You may have more than one “Rapid Strep” row or duplicates of other rows on a flowsheet, displayed as if they are two different lab tests. This happens when you use two different labs, or if your office switched from using a generic lab to one with discrete tests and results. In those situations, you may have to review two rows to understand a patient’s complete history with a lab test.

PCC recommends you configure your labs with discrete tests. Call PCC Support for help configuring labs or read the Lab Configuration article.

Tests and Orders From Before PCC EHR

If you used an EHR product before PCC EHR, your old system’s labs were probably not retrievable or stored in a discrete format.

During a PCC EHR online, incompatible labs from other systems are converted into notes in your patient’s visit history. They will not appear in the Flowsheets section of the patient’s chart.

Navigate a Patient’s Chart

August 3, 2015/in Get Started Review a Patient's Chart Review a Patient's Chart /by Douglas Beagley

After you open a patient’s chart in PCC EHR, you can use the navigation buttons on the left to review the full chart.

Watch a Video: Watch Review a Patient’s Chart in PCC EHR to learn more.

When you first open a chart, you will see the Medical Summary screen. You can navigate to different sections of the chart using the buttons on the left.

Each patient’s chart contains a Medical Summary, a Demographics section, a History section (which includes the Visit History, an Immunization History, Flow Charts, Growth Charts, and Documents), and a Prescriptions section.

If the patient has an appointment today, or the provider is reviewing an old chart note, the patient chart will also display a button for jumping to today’s chart note.

Other Chart Features

  • Return to the Schedule: Click the “PCC EHR” logo button to return to your schedule or other working queue.

  • See Patient's Most Recent Weight, percentile, PCP, and Active Policies At Any Time: As you review a patient’s chart, you can quickly review their most recently recorded weight, percentile, and their primary care physician.


    When you need patient weight for prescribing, or other basic patient information for another purpose, click on the patient’s information label in the upper-right corner. The weight appears with the date it was last taken, which can help you decide whether you need to check weight again.

  • Refresh and Conflicts: If multiple users in your office open and make changes to a patient chart, then the “Save + Refresh” button will turn yellow. Click the button to save your own changes and display any changes made by other users. PCC EHR records changes to a patient chart independently, by user; multiple changes can not conflict.

  • Room Number/Location: If the patient has an appointment today, and is currently placed in an exam room, their location will appear by the visit date.

  • Patient PCC #: The patient PCC # or “Patient Account Number” is a unique number on your PCC system. You can use this number to search and locate a chart quickly, and the number appears next to the patient’s name in the chart.

  • Duplicate Charts: If a patient appears twice in PCC EHR, they may have two patient records in the billing system. Contact your office’s billers to double-check the accounts. See Merge Duplicate Patients and Accounts.

To learn about specific chart sections, visit Review a Patient’s Chart.

Allergies

August 3, 2015/in Review a Patient's Chart, Prescribe Medications Prescribe Medications, Review a Patient's Chart /by Douglas Beagley

PCC EHR tracks allergies in each patient’s chart. When the chart is up-to-date, PCC EHR can automatically warn you about drug allergies as you prescribe, create lists of patients based on allergies, and display custom alerts whenever you work with a patient’s chart.

Review PCC eRx Allergies and Non-Drug Allergies Components

PCC EHR has two distinct allergy components. Your practice may use one or both of them to track allergies. By default, the components both appear on the Medical Summary screen.

The Allergies component is a chart-wide component on which you can record any allergy. The PCC eRx Allergies component has special features for handling drug allergies. You can edit the non-drug Allergies component wherever it appears, either on the Medical Summary screen or right on a chart note while charting a visit. The PCC eRx Allergies component is updated inside PCC eRx, the prescriptions section of a patient’s chart.

If you wish to view active, inactive, and/or resolved allergies, you can use the Display filter menus to change which allergy statuses should be visible. PCC EHR will remember your preferences across all charts.

Click “Edit” to add, edit, or remove allergy information on the non-drug Allergies list.


You can begin typing in an empty row to add a new allergy.

If an allergy is unlocked, it will appear in the patient’s chart as well as on patient reports and the patient portal. You can right-click on the allergy name field and select “Find Other Allergy” to search the entire diagnosis database. Right-click and select “Delete Allergy” to completely remove an entry.

Problems vs. Allergies: The list of available diagnoses in the Allergies component is based on SNOMED-CT descriptions, just like diagnoses that appear on the Problem List. How does PCC EHR knows that a diagnosis is an allergy? You can customize your diagnosis configuration to set up which diagnoses are available. Use the Diagnosis Configuration tool.

Work With Medication Allergies in PCC eRx

Visit the Allergies component in the PCC eRx section of a patient’s chart to work with medication allergies.


Click “Add New Allergy” to add a new allergy. You can also click “NKDA” to indicate the patient has no known drug allergies.



PCC eRx’s allergy search tool uses robust pattern matching, along with a library of drug reactions, making it easier to enter precise information about patient drug allergies. You can enter sensitivity type, reaction, severity, onset date, and comments.


During the visit, you can click “Mark as Reviewed” to indicate that you have reviewed drug allergies for the patient. The reviewed status will update in PCC eRx and on the Medication History component in the patient’s chart.


Allergy Report: PCC eRx includes an Allergy Report. Click “Print Allergies” to generate the report.


The Allergy Report includes allergy details along with a record of the last time someone at your practice clicked “Mark as Reviewed” in PCC eRx. You can save the report as a PDF or send it to a printer.

Allergies and Problems from the Chart Also Appear in PCC eRx

PCC eRx displays a patient Problem List that includes items from PCC EHR’s Problem List and all items from the non-drug Allergies component in the patient’s chart. You can use this information while making medication decisions.

Update Your ICD-9 Diagnoses: PCC EHR and PCC eRx track Problem List and non-drug allergy diagnoses using the SNOMED-CT coding system. If you still have historical ICD-9 Problem List or allergy diagnoses in a patient’s chart, you should update their records. The PCC eRx interface will not display ICD-9 diagnoses.

Allergies in Action: Prescribing Alerts

As you prescribe a drug, PCC eRx will alert you to any possible allergies as well as drug-to-drug interactions and other contraindications for the patient for the selected medication.

First, you will see proactive warnings in the search results when you search for a medication:

Next, you will also see reactive warnings when you create the prescription:

Recent and Upcoming Appointments

August 3, 2015/in Medical Summary Component Reference Medical Summary Component Reference /by Douglas Beagley

The Recent and Upcoming Appointments component, which can appear on the Medical Summary, Phone Notes, or any chart note, displays important information about a patient’s appointments at your practice.

The component can display the last visit (including diagnoses), last and next physical date, and any upcoming scheduled appointments.

Details

Where does the scheduling information come from, and how does PCC EHR figure out details like the clinician for an appointment or the next physical due date?

  • Last Visit: The Last Visit is calculated from the last charted visit in PCC EHR. The clinician indicated and any diagnoses are drawn from that chart note. (An appointment may be initially scheduled for one clinician and then changed on the chart note.)

  • Last and Next Physical: When a patient is billed for a physical code, the date of their last physical and the calculation of their next physical updates automatically, based on your practice’s well visit schedule. You can adjust a patient’s last and next physical dates in the Demographics section of their chart.

  • Scheduled Appointments: All upcoming scheduled appointments for the patient.

Configuration

The Recent and Upcoming Appointments component may appear on any PCC EHR ribbon, including the Medical Summary, Phone Notes, Patient Check-In, and visit protocols.

Using the Protocol Configuration tool, you can edit this component wherever it appears. For example, you might configure the component to display all visit types within the Medical Summary, but only future visit types in the Patient Check-In Ribbon.


You can configure which of the appointment types are visible by showing or hiding the Last Visit, Last and Next Physical, or Scheduled Appointments sections. You can also rearrange the order in which the appointments appear, and choose whether to use this component as an anchor in the protocol ribbon.

Reminders

August 3, 2015/in Medical Summary Component Reference Medical Summary Component Reference /by Douglas Beagley

Use the Reminders box on the Medical Summary screen to note important patient issues that everyone who opens the chart should see.

If the patient needs something done during a follow-up visit or has a pressing concern or issue, the Reminder box will help your office coordinate care around that issue.

Click “Edit” to make changes.


After making changes, you can copy or append the text to any of the patient’s siblings. Read the Medical Summary overview to learn how.

Siblings Component

August 3, 2015/in Medical Summary Component Reference Medical Summary Component Reference /by Douglas Beagley

The Siblings component includes a list of patient siblings and a button for opening their chart. It can appear on the Medical Summary, Phone Notes, or any chart note.

Click “Open Chart” to open a sibling’s chart side-by-side with the current chart. You can open up to four sibling charts at once.


For more information about working with multiple sibling charts, read the Review and Edit Multiple Sibling Charts article.

The Visit History Screen

August 3, 2015/in Review a Patient's Chart Review a Patient's Chart /by Douglas Beagley

The Visit History section of the patient chart in PCC EHR displays notes from all encounter’s in the patient’s history, including visit notes, portal messages, phone notes, unattached documents, follow-up tasks, e-prescribing encounters, and unsolicited e-lab results.


The Visit History Index at the bottom of the screen allows you to see a list of all encounters in the patient’s history. It displays the encounter date, the patient’s age at the time, which chart note protocol was used (if the item is a visit note), charted diagnoses, the provider of service, the number of document attachments, and whether there are outstanding tasks associated with the encounter.

Click on any item in the index to display its full details in the window above.


You can navigate through the detailed encounter notes using the scroll bar or by pressing Page Down and Page Up on your keyboard.

If an encounter has document attachments, the details pane displays a thumbnail of each one, as well as its associated tags. Click “View Documents” to view the documents and edit their details.

If notes appearing in the Visit History happen to be tied to an appointment that was missed or canceled, a missed or canceled status appears beside the encounter in the Visit History Index, as well as in the encounter notes.

Adjustable Visit History Index

You can expand or contract the Visit History Index, which displays a list of the patient’s visits, phone notes, portal messages, unattached documents, follow-up tasks, e-prescribing encounters, and unsolicited e-lab results.

Click and drag the dotted grow line along the top edge of the panel to change its size.

The index will reset to the default size when you leave the chart. The default size displays about six rows of information.

Display Visit History by Type

While reviewing the patient’s Visit History, you can filter the index to display only certain kinds of entries.

Click on the “Display” pull-down menu and select the history items you wish to view.

In order to ensure the patient record remains easy to review, the Visit History Index reverts to its default display (All History) when you close the chart.

Search the Visit History

You can search the Visit History for entries that contain a certain word or phrase.

In the Visit History Index, type a term into the Search Filter field, then click the Search button.


The Visit History Index adjusts to display a list of entries that contain your search term. Select an entry to view its details. Your search term appears highlighted in yellow in the window above.

You can jump between instances of your search term in the patient’s history by clicking the forward and back arrows beside the Search button.


Whichever instance of your search term is actively selected appears highlighted in orange in the window above.

Edit a Visit or Phone Note, Reply to a Portal Message, and Manage Tasks

You can open and edit any visit, phone note, or portal message encounter, and manage tasks from your patient’s Visit History. For example, you might need to complete charting tasks from a previous encounter, or create new tasks as a result of unsolicited e-lab results.

Find the entry in the Visit History Index, select it, and click “Edit”. Or, double-click on the item.


Print Notes from an Encounter

Select any encounter in the Visit History Index and click “Print” to print a copy.


Growth Charts

August 3, 2015/in Review a Patient's Chart Review a Patient's Chart /by Douglas Beagley

Growth charts display plotted growth data, such as patient weight, height, and other vitals over time.

You can review growth charts in the Growth Charts section of the patient’s chart. Click on the History button and then select “Growth Charts”.


Your practice can also add the Growth Charts as a component to chart note protocols or the Medical Summary.

PCC EHR plots patient data on each chart and also indicates percentile averages with gray lines. Percentile ranges are specific to a patient’s age and sex, and come from the World Health Organization (WHO) and the Centers for Disease Control (CDC).

PCC EHR updates growth charts automatically when you enter vitals on a visit chart note. You can also click “Add Points” to add details manually.

Review Point Details

Click on any point to see the relevant details and percentiles.

You can also review the details of the plotted points in the “Tabular Data” section. Click the triangle to hide or show the Tabular Data. The most recent visit appears at the top.

Growth Charts for Special Needs

Some children don’t meet the same threshold for growth data as others in their age and sex categories.

PCC EHR uses the Fenton Preterm growth charts for children born prematurely, and the AAP Down syndrome growth charts for patients who have a diagnosis of Trisomy 21.

Preterm Growth Charts

If a patient’s gestational age at birth indicates prematurity (less than 37 weeks), PCC EHR will display Fenton Preterm growth charts, until the patient reaches a gestational age of 50 weeks.

There are three preterm growth charts – one for weight, one for length, and one for head circumference.

You can enter a patient’s gestational age at birth in the Birth History component, either in the Demographics section of the patient chart, or while charting, if your practice has added this component to visit protocols. For help with configuring preterm growth charts, read the Configure Growth Charts article on learn.pcc.com.

After a patient reaches 50 weeks gestational age, the subsequent vitals percentiles and growth charts will revert to displaying the practice’s default data set (WHO or CDC).

Down Syndrome: For preterm patients with Down syndrome, PCC EHR will display the Fenton growth charts until the patient reaches 50 weeks gestational age, at which point it will switch to the Down syndrome growth charts.

Down Syndrome Growth Charts

If a patient has a Down syndrome diagnosis (Trisomy 21) on their Problem List, you will see the AAP Down syndrome growth charts by default.

Your practice can set which diagnoses cause the Down syndrome charts to appear. For help with defining which diagnoses will qualify for Down syndrome growth charts, read the Configure Growth Charts article on learn.pcc.com.

Multiple Growth Charts

You can select from several different comparison growth charts for different age ranges. Click on the pull-down menu or use the right and left arrow buttons to choose a different growth chart.

How Does PCC EHR Pick Which Growth Chart to Display?: When you open the Growth Charts section of a patient’s chart, or a chart note with the Growth Charts component, PCC EHR automatically selects which Growth Chart to display first based on a patient’s age, sex, and certain Problem List diagnoses (for Down syndrome growth charts).

WHO, CDC, or AAP?: By default, PCC uses WHO growth chart data for patients up to age two, and uses CDC data for all patients over age two. If a patient has a Down syndrome (Trisomy 21) diagnosis on their Problem List, then Down syndrome growth charts will be displayed by default. You can configure growth chart and percentile behavior in the Practice Preferences and the Growth Chart Configuration tool.

Body Mass Index (BMI) Growth Chart

PCC EHR automatically calculates BMI whenever the staff enters a height and a weight value for the same date. You can enter this data during a visit on a chart note or on the Growth Charts screen.

The BMI-For-Age Growth chart displays plotted points for the patient’s BMI percentile.

Print a Growth Chart

Select any growth chart and click “Print” to print it.

Remove Unwanted Data Points

If the patient has a faulty data point, or information obtained during a sick visit that does not properly reflect the patient’s progress, you may remove it from the growth chart by clicking on the “Show” toggle button in the Tabular Data list.

Add Growth Data Manually

Click “Add Points” and enter vitals or growth data to modify the patient’s records.


For each new record, enter a date and one or more measurement. Then click “Save”.

Add Growth Charts to Any Chart Note or Other Protocol

You can add growth charts to your chart note protocols (or any ribbon), which will enable clinicians to review growth chart information quickly while they chart a visit.

Use the Protocol Configuration tool to add the Growth Charts component to any chart note protocol.

Live Updating: If you enter new vitals into a chart note, as illustrated in the example above, click “Save” to update the growth charts in the chart note with the new vitals data.

Families Can View Growth Charts in the Patient Portal

Families can view Growth Charts in My Kid’s Chart, PCC’s patient portal. Families and patients will be able to look at their different growth charts at any time, right on their mobile device.

Growth Charts will appear on the “Health Information Summary” page of the patient portal.

Parents will be able to tap through the available charts for their child, using the arrows shown just above the chart.

For a larger view, parents can turn their mobile device sideways.

Patients and parents can view the specifics of each entry (including percentiles) by clicking on the “Measurements” button beneath the chart.


Your practice can control which charts are available for patient portal access in the Growth Chart Configuration tool, and you can remove Growth Charts from the patient portal entirely with the Patient Portal Manager tool.

Review and Update a Patient’s Immunization Record

August 3, 2015/in Review a Patient's Chart, Immunizations Review a Patient's Chart /by Douglas Beagley

Each patient chart contains an immunization record. You can review and update immunization dates and administration details, review a patient’s vaccine-preventable disease records, and see forecasting of a patient’s upcoming or missing immunizations.

PCC EHR updates the immunization record automatically when you create immunization orders on a visit chart note. Users can also review records and add items manually on the Immunization History screen.

View a Patient’s Immunization History

The Immunization History section of the patient’s chart displays the patient’s vaccine records. You can review immunizations, vaccine-preventable diseases, and forecasting of the patient’s upcoming immunizations.


The same information can optionally appear as a component on a chart note for a visit.

Immunization Forecasting

When you review a patient’s immunization record, either in a chart note or in the Immunization History section of the chart, PCC EHR can display a list of upcoming immunizations for the patient. PCC displays forecasting results and warnings from the Immunization Calculation Engine provided by HLN Consulting. The Immunization Calculation Engine uses a rule set built on the ACIP immunization schedule guidelines from the CDC.

Immunization Forecasting is an optional feature that relies on your practice’s specific immunization configuration. Learn more here.

Review Immunization Dates

Immunizations’ administration dates appear in chronological order, organized by vaccine family, as determined by your practice’s immunization configuration.
A normal vaccine record appears in black, as a single date of administration.
The immunization record may also indicate three special circumstances for an immunization, as show in the images above.

  • Contraindicated Immunizations: Immunizations that were ordered but not given may be marked as Contraindicated. a user may have entered notes or a contraindication reason, and you can click “Edit Imms” to review the details.

  • Refused Immunizations: Immunizations that were ordered but refused appear in red. You can click “Edit Imms” to review full details of the order.

  • Ordered Immunizations: Immunizations that have been ordered but not administered appear in the highlighted “Ordered” line. For more information about ordering and administering immunizations, read the Orders help articles.

Disease Diagnoses for Presumed Immunity

The Immunization record can also display presumed immunity for patients who have had vaccine-preventable diseases. If a patient is diagnosed with Varicella, for example, then Varicella will appear with a date in the patient’s Immunization History.


The Diseases section of the immunization record will also appear in the chart note and wherever immunizations appear. The section can display dates for any of the 28 diagnoses associated with vaccine-preventable diseases, whether the patient has had the disease or has serological evidence of immunity.

Which Diagnoses?: The 28 diagnoses supported by this feature are from the HL7 standard. They include 22 diseases such as varicella, measles, and anthrax. There are also 6 diagnoses that indicate serological immunity to a disease (as determined by an antibody titer test, for example).

Configuration Options: Your practice can configure how and when PCC EHR will display a date for each disease. To learn how, read the “Diseases” section of the article Configure the Immunization History Screen.

Diagnosed Diseases and Problem List Entries

Diseases will appear on a patient’s immunization record when the diagnosis is added to the Problem List or when they are diagnosed on a chart note.


The date for a disease is either the date of diagnosis or the onset date from the Problem List. You can hover your mouse over a date to view all available details, including the source of the date.

Old ICD-9 Diagnoses: Patients must have the SNOMED description of the disease in their chart for it to be evaluated as one of the 28 vaccine-preventable disease diagnoses. If a patient has 052.9 Varicella in their Problem List for chickenpox, for example, it will not appear in the Diseases section of the immunization record.

Immunizations and Diseases on Reports and Other Output

The patient’s immunization record, along with disease diagnoses, can appear on the Patient Visit Summary report, the Health Information Summary report, and on the patient’s school form.


Immunizations and diseases can also be sent to your state’s immunization registry. Contact PCC Support for help configuring where and how immunizations and diseases appear in your PCC system.

Print an Immunization School Form in PCC EHR

Click “Print” at the top of a patient’s Immunization record to generate your practice’s customizable school form.



If your office has multiple school form formats, you can select the one you want before printing.



If you don’t see the school form you expect, get in touch with PCC Support. A member of Support can help you customize and configure your school form(s) so they are available and print correctly from PCC EHR.

Customize Your Immunization Forms: Your practice can create multiple school forms, customize them with 4-digit years, and make other changes. Contact PCC Support for help.

Add Immunization Records Manually

Click “Add Imms” to add a vaccine to the patient’s records.



First, select a record source. Then select immunizations from the pull-down menu and enter dates.
When you are finished, click “Save”.

Best Practices and ACIP/CDC Guidelines for Historical Sources: When entering historical vaccine information, ACIP’s guidelines state, “With the exception of influenza and pneumococcal polysaccharide vaccines, if documentation of a vaccine dose is not available, the adolescent should be considered unvaccinated for that dose.” You may wish to consider these guidelines when using historical sources such as “Parent’s Recall” (ACIP, pg. 178).

Look Up and Import Immunization Records from Your State’s Registry

Practices in certain states and municipalities can retrieve and import a patient’s vaccine history from their local immunization registry without ever leaving PCC EHR.

Contact PCC Support if you are interested in using this feature once a connection has been established with your registry.

Click the “Retrieve Imms” Button

Click the “Retrieve Imms” button to request the patient’s immunization history from your state registry.

Confirm the Patient Match

Use the demographic comparison in the “Retrieve Immunizations” window to confirm that the registry found the right patient.

Click “Next” to view the patient’s vaccine history.

You Can Only Proceed with a Unique Patient Match: If the registry finds several possible matches for your patient or finds no exact matches you will not be able to retrieve the patient’s vaccine history from the registry within PCC EHR. Close the Retrieve Immunizations window and try looking up the patient’s vaccine history directly on the registry website.

Review the Information Sent by the Registry

Review the vaccine history from the registry. Dates that are already in the patient’s chart appear in a black font, while new dates appear in an orange font. You can decide what to do with the new dates on the next screen.

Click “Next” to begin importing new information from the registry into PCC EHR.

Immunization Registry Forecasting and Disease Data: Some registries send vaccine forecasting and/or vaccine-preventable disease data in addition to the patient’s vaccine history. You can view this information if the registry sends it, but you cannot import it into PCC EHR.

How Does PCC EHR Determine if a Vaccine is Already in the Patient's History?: For each immunization reported by the registry, PCC EHR checks to see if the associated CVX code and date already exist in the patient’s chart.

Import New Vaccine Dates from the Registry into PCC EHR

Select the immunizations and dates you wish to import from the registry into the patient’s PCC EHR record. You can only import new entries from the registry; entries that already exist in the EHR are excluded from the import window.

Once selected, immunizations from the registry are automatically mapped by CVX code to their equivalents in the EHR.

If a registry immunization has several equivalents in the EHR, all of the options are presented in a drop-down field in the import window. Review the options and manually select one to use for the import.

Sometimes new entries from the registry use CVX codes that are not configured in your PCC system. You must add the missing CVX codes to your immunization configuration in order to import these entries. Contact PCC Support if you need help adding CVX codes to your immunization configuration.

Once you have selected and mapped the immunizations you plan to import from the registry, click the “Import” button.

The information imports into PCC EHR and the Retrieve Immunization window closes on its own.

View and Edit Imported Entries in the Patient’s Immunization History

Information imported from the registry appears immediately in the patient’s Immunization History in PCC EHR.

You can view details about the immunizations imported from the registry by editing the patient’s Immunization History.


Historic immunizations imported from the registry are recorded in the patient’s chart with the source “Historical Record from Other Registry”. The imported entries can also include information about the vaccine dose, lot number, site, route, and funding source.

Review and Edit Immunization Details

PCC can record a wide variety of information about each vaccine administration. Normally, shot information is entered during completion of an immunization order. You can also review and edit that information in the Immunization History section of the patient’s chart.

Click “Edit Imms” to open the Edit Immunizations window.


Click the toggle arrow for a specific immunization to see shot details.

Click “Edit” to make changes to a shot.


You can edit and update each immunization’s VFC information, dose, lot #, manufacturer, VIS information, note, as well as whether the immunization was administered, refused, contraindicated, or canceled. When selecting certain options, such as Contraindicated, you can add additional details, such as a contraindication reason. All completed immunization orders can also include who completed the order and a date and time.

Delete an Immunization: Mark an immunization as Canceled to remove it from the patient record. If the date was manually entered, the record will be completely removed. If the immunization was charted during a visit, that record will remain in the patient’s Visit History. You can edit the order in the Visit History to make further changes.

Configure the Immunization History: Read Configure the Immunization History Screen to learn how to arrange, hide, or display immunizations on your office’s default screen.

Vaccine Lot Report: To run an immunization report on multiple patients (say, to determine which patients received a specific vaccine lot within a specific date range), you can run the Vaccine Lot Report.

Immunization Forecasting

August 3, 2015/in Review a Patient's Chart, Immunizations Review a Patient's Chart /by Douglas Beagley

When you review a patient’s immunization record, either in a chart note or in the Immunization History section of the chart, PCC EHR can display a list of the patient’s upcoming or missing immunizations.

Immunization Forecasting is an optional feature that relies on your practice’s specific immunization configuration.

Forecasting Results

When Immunization Forecasting is turned on for your practice, you will see details about the patient’s next recommended immunizations wherever the immunization history appears.

For each vaccine family, from left to right, you can see:

  • the next expected dose in the series (1st dose, 2nd, 3rd, etc),
  • the recommended date (when it is ideal to receive this immunization) along with the patient’s age on that date,
  • the minimum date the immunization could be given early,
  • a past due date,
  • and a maximum date after which the shot or series would be invalid. (Rotavirus is the only common immunization with a normal Maximum Date.)

In the example above, the Forecasting Results recommend that this patient receive their first HPV, sixth DTaP, and first Meningococcal vaccines during their 11 year visit, around 1/30/2016. The patient missed their second dose of Hepatitis A vaccine, and they also did not receive an annual flu shot for 2014. HPV appears first because the Minimum Date is past; today the patient is within the minimum recommend range for receiving their first HPV shot.

Your practice can review the forecasting information and make a decision about which shots to administer today.

Here are some notes to keep in mind as you review the Forecasting Results:

  • What Order Are Vaccines In?: Vaccines in the Forecasting Results window are in the order of the earliest date reached. That means that a vaccine that has met the Minimum Date may be in front of one that has reached the Recommended Date.

  • Bolded, Color-Coded Date Recommendations: If a Minimum Date has been reached, you’ll see that date in bold. That means the immunization can technically be given. If a Recommended Date has been reached, you’ll see it in bold green. Green means that today is a good time to give the shot, as the recommended date has arrived or just passed. If a shot or series is overdue, you’ll see the date in bold red.

  • Refresh the Record: PCC EHR updates forecasting results when you open a chart or whenever a user edits a patient’s immunizations or immunization orders. You can see the most recent updated date and time next to the section title. You can also click Refresh to update the immunization forecasting.

  • What is a Vaccine Family?: Common combination vaccines, such as MMR, are always listed as a vaccine family. This is because the single-antigen version of these vaccines (such as a Measles vaccine) are not used in the United States. If a patient does have a single-antigen version of a vaccine on their record, Immunization Forecasting will attempt to evaluate the dose accordingly.

Forecasting Warnings

A patient’s immunization record may also include a Forecasting Warnings section.

Each line in the Forecasting Warnings section will show a vaccine name, a date for an immunization from the patient’s record, and a message.

There are two types of warning messages:

  • Informational Warnings: A Warning message is informational. The vaccine is still acceptable towards the series and does not need to be repeated, but it may have been administered early or in a time frame that does not match the manufacturer’s recommendation. Warnings can be safely ignored but may be useful as you are reviewing a patient’s immunization record. For example, in the above image, a patient received an extra Hepatitis B vaccine.

  • Invalid Vaccines: An Invalid Vaccine warning is about a vaccine that may not meet the requirements for the vaccine series. Your practice should review all invalid vaccines.

    In the above example, a patient received their fourth DTaP shot too early.

Show or Hide Informational Warnings: Warnings can be distracting. You can deselect the “Show Informational Warnings” checkbox to hide them. Invalid Vaccine warnings can not be hidden, and they will appear even if the “Show Informational Warnings” checkbox is deselected.

Where Do Forecasting Recommendations Come From?

PCC displays forecasting results and warnings from the Immunization Calculation Engine by HLN Consulting. The Immunization Calculation Engine uses a rule set built on the ACIP immunization schedule guidelines from the CDC.

Forecasting results and warnings do not represent medical authority in deciding which immunizations a patient should receive. Your practice may adhere to a custom immunization schedule and make different decisions. The Immunization Forecasting section bases its recommendations on the ACIP guidelines.

For example, if a patient’s record indicates a dose that does not meet ACIP criteria, you may see a recommendation for that dose to be given. You may also see a Forecasting Warning about the invalid dose.

New Immunizations, Rules and Periodic Updates to Immunization Recommendations

ACIP guidelines and immunization schedules can change over time. PCC has a team that reviews and considers each update to the Immunization Calculation Engine.

Once the team approves a new update or change to forecasting rules, it is reflected in the Immunizations component for all PCC practices.

PCC announces these updates in our release documentation, and depending on the size and impact of the update will also communicate the changes on PCC Community and through the PCC Newsfeed.

Forecasting and Patient or Diagnosis Contraindications

The immunization forecasting features of PCC EHR will ignore contraindications in the patient history for “Current” reasons, i.e. illness or pregnancy.

If a patient has a persistent contraindication reason charted for an immunization, such as intussusception history (a contraindication for the rotavirus vaccine) or immunodeficiency (a contraindication for live vaccines), then the corresponding vaccine family will no longer appear in Forecasting Results or Forecasting Warnings.

As always, clinicians should remember that immunization forecasting in PCC EHR is a just calculation based on ACIP immunization logic, and not a medical decision. While the forecasting and immunization warnings will understand and accommodate diagnosis contraindications or exceptions to rules that it knows about, the dates shown are advisory and are not a substitute for a physician’s decision.

Understanding an Invalid Vaccine Warning

There are many reasons a vaccine dose may be considered invalid.

  • A dose in the patient’s history may not meet the ACIP schedule.
  • The patient may not have had the required 28-day interval between live vaccines.
  • The recommended Polio vaccine schedule changed significantly in 2009 (dose 4 should now occur after 4 years of age with a 6 month interval from dose 3).
  • Other vaccine guidelines may have changed.

If your practice believes an Invalid Vaccine warning is in error, please contact PCC Support at 802-846-8177 or 800-722-7708 or support@pcc.com.

Immunization forecasting in PCC EHR is a calculation based on ACIP immunization logic. The dates shown are advisory and are not a substitute for a physician’s decision.

Configure Immunization Forecasting

Immunization Forecasting is an optional feature. Contact PCC Support to turn it on or off.

Accurate forecasting requires that your practice indicate (by CVX code) which versions of each immunization your practice gives.

You can also configure which immunizations appear in PCC EHR and how they are tracked and displayed.

Read Add and Configure Immunizations to learn more.

Patient Arrival and Checked In Statuses

August 3, 2015/in Get Started in PCC EHR, Check In a Patient Check In a Patient /by Douglas Beagley

When your office checks in a patient, or when you click “Patient Arrived” or create a new visit while viewing a chart, PCC EHR indicates that the patient is here in the Visit Status column.

The starting Visit Status is “Scheduled”, which then switches to either “Checked In” or “Arrived”. The optional “Arrival” column indicates when the patient was checked in (or when the user clicked “Patient Arrived”). The Arrival column is optional, and can be turned off in the “Practice Preferences” tool, found under the Tools menu.

Change Status and Location: You can click on the green button to rotate the status as the patient becomes ready for the provider, a nurse is needed, and so forth. You can set their location using the drop-down menus in the “Room” column.

You can also change the visit status at the top of any chart note.

Status Counters: The Status Counter numbers in the lower-right corner of your screen display the total number of patients Arrived and Checked In, as well as other visit statuses.

Change the Clinician?: If you need to change the assigned clinician for an encounter, you can double-click on the chart note to open it and change the provider field at the top of the screen.

Work with Today’s Patients on the PCC EHR Schedule Screen

August 3, 2015/in Get Started The Front Desk and PCC, Get Started in PCC EHR Get Started in PCC EHR /by Douglas Beagley

The PCC EHR Schedule screen contains a list of patient appointments and tools for using that list.

Each appointment on the list displays: the Visit Status, patient room location, the appointment time, patient name, date of birth and sex, visit reason, the scheduled (or assigned) provider, the billing status of the visit, and who it has been signed by.

Optional fields, which can be turned on and off in the Practice Preferences tool, include the patient’s arrival time, the patients age, and an outstanding tasks indicator.

Open a Chart: While viewing the schedule, you can open any patient’s chart by double-clicking on their name or by selecting them and clicking “Open.” You can also find any patient’s chart by using the search field and clicking “Find.”

Patient Management

The Schedule screen displays visit statuses and additional information to help you manage patient flow in your office. The green visit statuses indicate the current activity of patients in your office, and you can review room and arrival time quickly.

Visit Status and Room

Click on the Visit Status buttons to change the status, and use the pull-down “Room” menu to assign a room. When a patient has left, click “End Visit” and the status will switch to “Gone”. These statuses are customizable; read the Visit Status Configuration document to learn more.

Special Features:

  • If you need to return a Visit Status to “Arrived” select the appointment and select “Reset Status to Arrived” from the Edit menu.
  • When you set the patient’s room, the information will appear in the chart for any user.

  • Visit Status Counters are an optional feature that can be used to track the number of patients with a specific visit status.

    Read the Visit Status Configuration document to learn more about customizing Visit Status Counters.

Telemedicine Visits

Visits scheduled as telemedicine visits will appear with a telemedicine icon in the Room column.

The chart notes for these encounters can contain components that are unique to telemedicine visits. Read more about scheduling, charting, and billing telemedicine visits here.

Tasks

The optional “Tasks” column indicates whether or not the patient has outstanding orders with incomplete tasks for the appointment. You can use this column to determine whether or not a patient may go home.

Depending on the orders a patient has and those orders’ statuses, different images will appear in this column:

  • Blank: Patient has no orders for this visit.
  • Checkmark: All orders are complete (tasks finished, results entered, immunizations administered).
  • Orange Ball: Incomplete orders (tasks unfinished, missing lab results, and/or pending immunizations).
  • Orange Ring: Incomplete orders, but the patient is done for the day (probably awaiting test results).

You can click on the tasks column to open a list of all the orders for the visit and work on the orders.


Twice in One Day, or Multiple Days: The Schedule screen, Tasks column, and Edit Orders window deal with each appointment separately. Therefore, if a patient has multiple visits on a single day or across several days, you should look at each appointment entry to check their Task column. Or, use the Visit Tasks queue to review and work with all incomplete orders.

View Appointment Notes on Your PCC EHR Schedule

As you review today’s schedule, you can quickly review appointment notes for each encounter.

If an appointment has an appointment note, you will see a triangle in the Visit Reason column.


Click anywhere on the visit reason to show the note.

Visit Type Color Code: If your practice defines visit types by color, then the appointment note triangle will also display the color of the visit type. That means anyone at your practice can quickly see which appointments are sick, well, or consults, for example. You can configure Visit Types in the Visit Reasons Editor.

Billing Statuses for Encounters

You can track the billing status of visits from the Schedule Screen.

If you are a biller, the Billing Statuses will appear as buttons, which you can use to open the Post Charges window for an encounter.

The billing statuses are:

  • Ready to Post: Once the clinician marks an encounter “Ready for Billing”, it will appear as “Ready to Post” on the Schedule queue.

  • Posted: After someone at your practice reviews and posts the charges, the Billing Status column will indicate that the encounter is “Posted”.

  • New Items: If a diagnosis, lab or order has been added to an encounter after it was posted, it will appear as having “New Items”.

If you are a biller, you may want to use the filters on the schedule screen to see just the encounters with the billing statuses you want.

How Do I Post an Encounter That Is Ready to Post?: To learn more about the billing status and how to post charges, read Post Charges in PCC EHR.

Signing Status of Encounters

The name of every provider who signs an encounter will appear in the “Signed” column.

Billers can see whether or not an encounter was signed right from the schedule screen.

Co-signing: If an encounter still needs a co-signer, the designated co-signer’s name will appear in orange until a clinician co-signs the encounter.

The Calendar

You can enter a new date, or view the next or previous day by clicking the arrow keys. You can also click on the calendar tool and select any date.


Note: Selecting an old date or a future date provides a quick way to open a patient’s chart directly to the chart note for that visit. You can also open any patient using the Find field and then open an old chart note from the Visit History screen.

Filter the Appointment List

You can limit which appointments appear using the filters at the bottom of the schedule screen.

Once you have selected filter options, such as viewing only appointments for a specific provider, that selection will remain in effect until you log out of PCC EHR.

Save Your Defaults: Users may wish to see particular providers, locations, or visit statuses whenever they log in. After selecting your specific providers, location, and which patients should appear, click Save My Defaults to save your login settings.

The Ready-Provider Status Counter Number Comes From the Filter Settings on Each User's Schedule Screen: The Ready-Provider Status Counter number is the total number of patients on each user’s customized Schedule screen that have the “Ready-Prov” status. For example, if Dr. Casey is covering for both herself and Dr. Williams, she can change her Schedule to show both sets of patients.

Return to the Schedule (or Other Queue) at Any Time

While viewing a chart, click the PCC EHR logo to return to the schedule, or whichever working queue you last viewed.

Configure the Schedule

For more configuration options, read Configure the Schedule Screen.

Your Financial and Clinical Pulse Scores in the Dashboard

August 3, 2015/in Review Practice Benchmarks Dashboard Pediatric Benchmarks For Your Practice /by Douglas Beagley

The Financial and Clinical Pulse pages in your Practice Vitals Dashboard display a detailed explanation of your practice’s overall health. The colored gauge on the front page gives you an at-a-glance idea of how your practice is doing compared to national metrics.

Click on the Financial or Clinical Pulse navigation links to view a Pulse page.


Your pulse scores provide a quick summary of your practice’s health in a number of key areas. On the Financial and Clinical Pulse pages, you can see an explanation of the different components that make up the Financial and Clinical Pulse scores. You can follow links to each of the metrics involved.

The descriptions and comparison measures are a great launching point for evaluating your practice’s performance and planning for the future. For example, you can review the different Immunization measures that make up your practice’s Clinical Pulse score:


You can then select one of the measures to learn more and drill down to more specific information. For example, the “Immunization Rates – Patients 2 Years Old” measure provides overall guidance and a detailed breakdown of vaccination rates for patients up to two years old, a vital age range for vaccination.

Log In and Review Your Practice Vitals Dashboard

August 3, 2015/in Get Started Review Practice Benchmarks Dashboard Pediatric Benchmarks For Your Practice /by Douglas Beagley

Follow the procedure below to log in to your practice’s dashboard and review your benchmarks and other data. To get a Dashboard login or to set up Dashboard access through the EHR, contact PCC support at 802-846-8177 or 800-722-7708. We’ll set up your practice’s username and password for the Practice Vitals Dashboard.

Log in using PCC EHR

Open the Practice Vitals Dashboard

Open the Practice Vitals Dashboard from the Reports menu in PCC EHR. Since you are already logged in to the EHR, you do not need to enter any additional login credentials.


Access to Your Dashboard: Your practice administrator can turn access to your practice vitals dashboard on or off for any user. Contact PCC Support for assistance.

Log in using your web browser

Visit http://dashboard.pcc.com

Enter http://dashboard.pcc.com into a web browser.

Enter Your Username and Password

Type your practice’s Practice Vitals Dashboard username and password in the upper-right corner.

If you do not know your username and password, contact your office’s System Administrator.

Using the Dashboard

Review the Dashboard Home Page

The Practice Vitals Dashboard homepage summarizes your practice’s overall health based on measures relevant to pediatric practices.

On the left, you can see a visualization of your summary. On the right, you can review a list of priority areas.

Underneath your practice status, a Dashboard News section keeps you up-to-date on recent developments and learning opportunities.

Click on a Priority Link

Click on any of the dashboard priority measure links to view details on that dashboard measure.


You’ll see an explanation of your score, comparison charts, trends, and recommendations. From the top of each details page, you can use the pull-down menu to navigate to any other measure.

Many measures include links to additional information, patient lists, and per-provider assessment.

Click on a Dashboard Section

In addition to reviewing specific measures, you can click on the navigation menu to view your Financial or Clinical Pulse pages as well as pages for EDI, PCMH, Productivity, and Patient Population.

The two pulse pages explain your practice’s scores and provide links to more information.

The other pages display data in custom reports with interactive forms.

Prepare an Encounter For Billing

August 3, 2015/in Get Started Select Codes and Make an Encounter Ready For Billing, Select Codes and Make an Encounter Ready for Billing Select Codes and Make an Encounter Ready For Billing /by Douglas Beagley

After you chart a visit in PCC EHR, click “Bill” to review and adjust billing diagnoses and procedures, review and adjust linking, and make the encounter ready for billing.

Read the procedure below to learn how to prepare a visit for billing, how to review what was billed, and more.

These steps are typically performed by the clinician, though other staff may perform some steps.

Watch Video Examples: Watch Prepare an Encounter for Billing to learn how a clinician prepares an encounter for billing in PCC EHR. For an overview of the Post Charges billing workflow, watch Post Charges in PCC EHR. You can also watch phone consultation and telemedicine demos.

Chart Diagnoses, Procedures, Labs, and Other Orders

When you chart an encounter, you enter diagnoses in the Diagnoses component. You might also order labs, medical procedures, screenings, immunizations, and other billable orders.

Click “Bill”

When you are ready to prepare the encounter for billing, click the “Bill” button.

One User: To prevent over-writing each other’s work, only one PCC EHR user may open a particular visit’s Bill screen at a time.

Optional: Change the Provider of Service

When you need to select a different billing provider, you can make that change at the top of the Bill window.

Alternatively, the biller can make that adjustment later, when they post charges. You can change the billing provider without changing the scheduled appointment provider. PCC EHR’s records will display both the Appointment Provider and the Provider of Service in the patient’s Billing History.

When Would I Need to Change the Provider for an Encounter?: Your practice might schedule a stand-in “Flu” provider in the Appointment Book. Then on the day of the encounter, you might change the scheduled clinician for the appointment to Nurse John, who gives the patient the flu shot. Afterwards, when you prepare the encounter for billing, you might define the supervising Provider of Service as the credentialed M.D., Dr. Williams. PCC supports these and other workflows.

Review and Adjust Diagnoses

In the Bill window, review all the diagnoses that came from either the Diagnoses component or an order. For each diagnosis, you will see an associated billing code (ICD-10).

The Bill window consolidates diagnoses. For example, when your practice orders multiple immunizations, PCC will consolidate the Z23 diagnosis into a single entry.



In the Bill window, all orders that have the same configured diagnosis will appear on a single line.

Enter Diagnoses on the Chart Note: If you missed a diagnosis, you should close the Bill window and add it to the chart note. PCC EHR adds all charted diagnoses to the electronic encounter form. You can enter new diagnoses in the Bill window for specific billing situations, but those items will not become part of the patient’s medical record unless noted on the chart note.

No Billing Code?: If a diagnosis from the chart does not have a mapped, ICD-10 billing diagnosis, you can select one on the Bill screen. Or, you can forward the SNOMED description for your billing staff to adjust later.

Review and Adjust Procedures (and Select a Visit Code, Supplies, and Other Items)

Next, review and adjust the billable procedures that came from the chart note. Select any additional procedures needed for billing purposes. For example, you can select a visit billing code, such as an E&M code, phone consult, or similar code for the encounter.

  • Why Did PCC EHR Select Certain Procedures Automatically?: Your office’s billing configuration determines which procedures appear when you order each lab or other procedure, along with what additional optional items will appear because of those orders.

  • Are the Labs Complete?: Procedure codes for your orders will appear in the Bill window as soon as they are ordered. Your staff may have not yet completed the labs, immunizations, or medical procedures. Review the chart note, the Visit Tasks queue, or the appointment’s Edit Orders window to check the status of orders.

  • Well Child Code: The encounter form can automatically display your practice’s age-appropriate well visit code, as shown in the screenshot above, or you may see a list of well visit billing codes.

  • Customizable: The Bill window, also called the electronic encounter form, is customizable. You can add your most common procedures to save time. Learn more by reading Configure Billing in PCC EHR or contact PCC Support for assistance.

Optional: Add Unusual Items

The encounter form only displays your practice’s preferred procedures. Click in a blank field and enter a name or code to search for less-common procedures.

Click “Next”

Click “Next” to continue to the second step of the Bill window.

Link Diagnoses to Procedures, Adjust Units

PCC EHR automatically links billing codes for orders based on your practice’s configuration. You can configure order linking in the Billing Configuration tool. PCC EHR will also link all procedures to a diagnosis when the encounter has only a single diagnosis.

When there’s no configured linking for a procedure, you can use the line letters (a, b, c, d…) to indicate which diagnoses should link to each procedure on the claim. Your biller can review this later, when they Post Charges, but the clinician decides which diagnosis corresponds with each billable procedure.

You can type the letters in the field or click and drag each diagnosis to the corresponding procedure. After making your selections, you can confirm that the appropriate diagnoses appear underneath each procedure on the right.
You can also adjust units for each procedure using the numeric field next to each procedure.

Optional: Save and Close the Encounter Form Without Making it Ready For Billing

Do you need to go back to the chart note and update something? Click “Save + Exit” to return to the chart note without releasing the procedures and diagnoses for billing. You can reopen the Bill window when you are ready to make the encounter ready for billing.

Make Ready for Billing

Click “Make Ready for Billing” to save your adjustments and update the status of the encounter. Your billers will then be able to post the charges.

Optional: Add Additional Items, Grab Back the Encounter Form

If you missed a diagnosis or procedure, you can add them to the chart note. PCC EHR will make any new diagnoses or procedures available to the checkout staff, though they will appear as unlinked.

Optionally, you can click “Edit Billing” to pull back the encounter before the charges are posted. Then you can clean up your additions and perform linking.

While you are making changes in the Bill window, other PCC EHR users can not select the encounter and post charges.

Sign the Chart Note

When you are finished charting, click “Sign” and sign the chart note. In addition to this being a general best practice, your billing staff can see the signers and co-signers for each encounter and may use that as a signal to know an encounter is ready to be billed.

Later: Select Visit and Post Charges

At any time after you make an encounter ready for billing, your practice’s checkout or billing staff can select the visit and posts the charges.

Read Post Charges in PCC EHR to learn more.

Later: Review What Was Billed, Add Additional Items

After your practice posts charges for an encounter, the clinician can no longer make changes in the Bill window. However, any user can click “Billed” at the bottom of the chart note to review the Electronic Encounter Form.


Also, the clinician can still chart new diagnoses and procedures. Billers will see the “New Items” status and can add the diagnoses and procedures to the claim later.

To review what was billed, along with all posted procedures, diagnoses, payments, and a claim history, visit the Billing History. Read Review an Encounter’s Billing History to learn more.

Later: Catch New Additions

PCC has a variety of tools for proving out, catching any missed charges for an encounter, and reviewing what was posted. For more information, read Find Encounter Charges that Need to Be Posted.

Schedule a Walk-In or “Add-On” Patient Visit

August 3, 2015/in Get Started Schedule a Patient Schedule a Patient /by Douglas Beagley

Follow the procedure below to create a visit for a patient in PCC EHR.

Enter the Patient’s Name and Click “Find” or Press Enter

Type the Patient’s name in the Find search box at the top of the screen. Press Enter or click “Find” to perform the search.

You can also search by phone number, chart number, and birth date. You can even set up custom search values.

Double-Click on the Patient Name

From the search results, choose a patient and double-click on their name.

Click “Create Visit”

If the patient already has a visit today, the chart note navigation buttons will appear. Otherwise, click “Create Visit”.

Enter Visit Details and Click Save

Choose an appointment time, visit reason, clinician, and location. The default time will be entered when you click “Create Visit”.

Begin Charting

A chart note for the visit will open immediately, and you can begin charting.

Check In and Followup On Tasks

The new appointment will appear on the Schedule screen. Your staff can use the Checkin tool to check insurance eligibility, confirm demographic information, and perform other functions.

Note: After you create a walk-in appointment for a patient, you may review their chart, begin charting the visit, or return to the Schedule screen. The patient’s new appointment will be waiting on the Schedule when you are ready to see the patient.

Create a Phone Note

August 3, 2015/in Get Started Triage a Phone Call Triage a Phone Call /by Douglas Beagley

When the phone rings, follow this procedure to enter a new phone note in a patient’s chart and (optionally) create orders, follow-up phone note tasks, and perform other actions for the patient.

Create a New Phone Note

Find the Patient

First, locate the patient in your records. Type the name in the Find field and click “Find”.


You can also search by chart number, birth date, or find a patient by reviewing the Schedule screen and opening their chart.

Create a New Patient or Account: If the patient or family has never contacted your practice before, you will need to create a new account and patient.

Click “Add Phone Note”

In the lower-right hand corner of the Find results, click the “Add Phone Note” button to begin a new phone note.

Note: If you have already opened a chart, you can click “Add Phone Note” on the Medical Summary screen.

Enter Contact Information and Call Details

Enter the name and call-back information for the caller. Note that PCC EHR tracks each patient’s contact information, so previous information for this patient may be available in the pull-down menus.

AutoFill: As you begin typing the contact name, phone number, or other information, PCC EHR will show you options from the patient’s records. You can use the arrow keys to select an option from the menu, and then press Enter to select one.

Requires Doctor Review and Signature?: If this phone note requires a provider review and signature, indicate the provider in the field on the right.

Deleting Numbers: If you have entered numbers in the past that are incorrect or no longer valid, you can right click in the Return Phone field to delete them.


Enter Phone Note Text

Type details from the call into the Phone Note field.

Enter a Subject

Type an overview or summary of the call into the Subject field. The subject appears on the Phone Tasks queue and in the patient’s Visit History index. A good subject makes it easier to track down notes from an old call.

Review Chart Details

At any time, you can use the chart navigation buttons to visit the Medical Summary, the Visit History, or other sections of the chart. For example, you might need to review a patient’s immunization records. The Phone Note will remain open and available, and you can return to it to pick right up where you left off.

Optional: Create a Task

If the family or patient needs a callback, an appointment, a prescription, or some other work, you can create a phone note task underneath the note’s text.

Enter the task, the assignee, and any relevant notes in the fields provided. You can use the “Task Completed” line to track when, and by whom, the task was completed. Tasks will appear on the Messaging queue in PCC EHR so the appropriate person can see the task and respond.

More than One Task?: Sometimes a patient will need a lab result, a callback from a provider, and/or a new appointment. As soon as you create a phone note task, a new blank task box will appear below the existing one. You can create multiple tasks for a single phone note, if needed. Any user can open the phone note and add additional tasks later.

Complete the Task Right Away: Phone note tasks are a good way to record any work done. You may create a task and complete it yourself, while still on the phone with the patient.

Optional: Create an Order, Add Additional Information, Send to Billing

If a patient needs a referral, a lab, or other action that your practice tracks using an order, you can click “Order” to create the order. Phone Notes are customizable, so your practice can decide what kind of orders should be readily available during a phone note and add the appropriate components.

When you create an order for a patient, it appears on the Visit Tasks queue, on the patient’s Outstanding Tasks component, and in the patient’s Visit History. Your practice can complete it using the same order workflow you use for orders created during a visit encounter.

In addition to orders, your practice’s customizable phone note protocol can include a place to record diagnoses, other patient information, and more.

How Do You Bill for a Phone Note?: You can create orders, select diagnoses, and make phone notes ready for billing, just as you would a scheduled, in-person encounter. To learn how, visit Bill For Phone Calls and Portal Message Encounters (Video, Article).

Orders May Require More Information: A referral, lab order, or other order may require additional details, such as a diagnosis, a location, and a provider. You can enter that information right on the phone note. For full details on creating orders and other order-related features, read Order a Lab, Procedure, Supply, or Other Order.

Visit History in Patient Portal: While phone notes are included among the visit history in PCC EHR, they are not visible in the Patient Portal.

For more information about phone notes, read Review Phone Notes.

Delete a Phone Note

If you start to create a phone note by mistake, you can close the patient’s chart and elect not to save your changes. The phone note will not be added to the patient’s records.

If a phone note has already been saved, and is part of the patient’s record in the Visit History, users with the correct administration privileges can open it from the Visit History and then delete it from the Edit menu.

Review Patient Phone Note History

August 3, 2015/in Triage a Phone Call Triage a Phone Call /by Douglas Beagley

A phone note record is stored just like any patient visit: in the Visit History, in the chart. Open a chart and click on Visit History to review all previous phone notes.

In the Visit History Index, click on a phone note to review its details, including all work done on the note and the users involved.

Double-click or select any phone note and click “Edit” to open it and make changes.

Visit History in Patient Portal: While phone notes are included among the visit history in PCC EHR, they are not visible in the Patient Portal.

Work on Messaging Tasks, Document Tasks, Call Backs, and More

August 3, 2015/in Triage a Phone Call Triage a Phone Call /by Douglas Beagley

Use the Messaging queue to view phone notes and tasks related to calls and portal messages. You can also find other communication-related work on the Messaging queue, such as lab follow-up calls, amendment requests, and document tasks. If you are a biller, you can post charges for billable phone and portal message encounters right from the queue.

Click the Messaging tab to view the queue and work on messages and messaging tasks.


Where Do Messaging Tasks Come From?: You can create messaging tasks while creating or editing a phone note, working with a document, or charting an amendment request. Patients and families may send them to your practice with My Kid’s Chart, the patient portal. Clinicians might create them while using Pocket PCC. Physicians can also create order follow-up tasks while reviewing and signing orders.

Filter the Tasks List

By default, the Messaging queue displays all incomplete tasks (including unanswered portal messages). You can filter the list by task, assigned user, billing status, due date, day, and task status. If you were a nurse responsible for incomplete nurse tasks, for example, you might filter to certain task types or clinicians. You can click “Save My Defaults” to make your filter settings your new default.

By default, phone notes are only displayed if there is a task to complete. If you wish to review phone messages that have no tasks, select the “No Tasks” Display filter setting.

In the Subject column, each type of message is represented by an icon:

 

Filter By Location: If your practice has multiple Care Centers, you can filter the Messaging queue by Care Center Location. For more information, read about the Care Center features in PCC EHR.

Filter By Billing Status: If you are a biller, you may not need to worry about most callbacks or clinical communication. You may only want to see communication encounters that are ready to bill, or that have new items added to them for billing. You could set the Billing Status filter so your Messaging queue and queue count only showed “Ready to Post” and “New Items” encounters.

Review Which Messages are in Use

Any task currently being viewed by another user is marked with a silhouette icon in the Status column. Hovering your mouse pointer over the icon shows which users are in that task.

Search Task Lists

If you’re looking for a more specific task or tasks in your filtered list, you can search through task text to quickly find the task you’re looking for, no matter how many items are on your queues.

Click the magnifying glass icon above each queue to reveal the search box. PCC EHR will automatically search when you finish typing, and the queue will refresh and show only items that include your search term.

Search looks through the details of each task in the queue, more than just the column headings. You can search for specific names, orders, subject lines, e-lab result, or phone note to find exactly what you’re looking for.

Search only includes items in your current view. If you’re using filters, only the displayed items in the task list will be searched.

To return to the full list, just delete your searched text and the queue will reset to the complete list of items.

Post Charges for a Phone Note or Portal Message Encounter

When a clinician selects diagnoses and procedures during a phone call or portal message encounter, they can click “Bill” and make that encounter ready for billing. Depending on their filter settings, the encounter will appear on the biller’s Messaging queue.

The biller can click “Ready To Post” to open the encounter and post charges.

For a complete guide to this workflow, review Bill for Phone Notes and Portal Messages as Telemedicine Encounters.

Phone Notes and Tasks

Double-click on any phone note task to open the patient’s chart and view the related phone note and all associated tasks.


The cursor will jump directly to the note field for the task you selected, so you may begin typing details about the task immediately. You can take notes and click the “Task Completed” check box.

You can change the task assignee to a different PCC EHR user, if this task should go to someone else.

If something more needs to be done regarding the phone note, you can send another task to any user by clicking on the “Add Task” button.

If you need to add notes to the phone note, you can do so in the Phone Note field, above the task(s). Your name will be added in brackets when the note is viewed from the patient’s Visit History.

Portal Messages and Tasks

Double-click on a portal message task to open the patient’s chart and view the message and any associated tasks.


You can respond to a portal message by typing your note in the Reply field and clicking “Send”. The message will be sent back to the patient portal, where the portal user will see it.

You can also add a task for someone else in your office, if needed. Tasks attached to portal messages work the same way as phone note tasks.

FYI Only?: If you don’t need to reply to a portal message, you can simply click “No Reply” and the message will be removed from your incomplete tasks list.

Orders Follow-up Tasks

If a physician creates a task on an order in the Sign Orders window, the nurse or other clinician will find it on the Messaging queue along with phone notes and other messages. They can double-click to open up the follow-up task.


Just like phone notes, an Orders Follow-up note is a customizable ribbon. By default, it contains the lab test results and all the information needed to call the patient or family, discuss the results, or perform other actions related to the order.

Order Follow-up notes also appear in the patient’s Visit History, for later review.

Amendment Requests

When an amendment request, is made, the doctor or other assigned clinician will be able to accept or deny the request from their Messaging queue.


When the user selects an amendment request task, the patient’s chart will open to the visit chart note that is in question, and scroll directly to the amendment request.

You can add a Decision Note and accept, deny, or cancel the request.

The history of the request will remain on the chart note. Amendment requests can be reviewed in the Visit History section of the patient’s chart.

Document Tasks

Double-click on any document task to open the document and view all associated tasks.


Beneath the task(s), you will see contact information to help complete many tasks. For example, if you needed to call back a patient’s mom about a document, the contact information and communication preference would be right there.

Practice Vitals Dashboard Overview

August 3, 2015/in Get Started Review Practice Benchmarks Dashboard Pediatric Benchmarks For Your Practice /by Douglas Beagley

The Practice Vitals Dashboard is a tool for tracking and reporting your practice’s financial and clinical health based on relative performance in a variety of areas. The dashboards provide a series of graphs along with reports and other statistical data to help you evaluate and improve your revenue, coding, clinical benchmarks, claims, and practice productivity.

With your Practice Vitals Dashboard, you can:

  • See a quick overview of your practice’s current financial and clinical indicators
  • Drill down on any indicator for a detailed trend analysis
  • Compare your financial and clinical data to national and regional pediatric benchmarks

PCC’s Practice Vitals Dashboard is available to all PCC clients.

Visit dashboard.pcc.com to get started. Read the articles in this section to learn more.

Create Recurring Notifications for Patients and Families

August 3, 2015/in Phone Vendor Integrations Phone Vendor Integrations /by Douglas Beagley

When you need to contact patients and families, the fastest way is to send Broadcast Messages (Video, Article) in PCC EHR.

PCC Support can also help you set up recurring notifications with the under-the-hood Patient Notification Center, which delivers messages through a partnership with TeleVox by phone call, text message, or email.

Read the sections below to learn what’s possible through the Patient Notification Center and TeleVox.

Get Started

Contact PCC Sales when you are ready to get started. The Patient Notification Center uses a TeleVox interface, which requires a setup fee and per-contact fees. PCC’s sales and support teams can help you understand the features, the cost, and help you decide if it is a good match for your needs. Next, we’ll register you with TeleVox (also known as Intrado).

Once you are signed up, PCC Support will work with you to configure your system for the Patient Notification Center. We’ll help you pick options, such as preferred languages, contact methods, and more.

Finally, PCC Support can also train you how to review a log of notifications and, if you wish, how to tweak and refine your notifications using PCC’s under the hood configuration tools.

What Do Notification Messages Sound or Look Like?

Phone Calls

Here are the voice messages for various notification types. These messages are created byTeleVox and are not customizable.

Appointment Reminder w/ Clinician’s Name Hello. This is the office of Dr. James Smith at Pediatric Associates calling to remind Johnny of an appointment at 9:00am on May 15th, 2012.
Appointment Reminder w/o Clinician’s Name Hello. This is Pediatric Associates calling to remind Johnny of an appointment at 9:00am on May 15th, 2012.
Due For a Visit Notification w/ Recall Reason Hello, this is Pediatric Associates calling with a reminder that Johnny is due for a <recall reason>. Please call us at 802-846-8177 or 800-722-7708 to schedule an appointment. We look forward to hearing from you soon
Due For a Visit Notification w/o Recall Reason Hello, this is Pediatric Associates calling with a reminder that Johnny is due for a visit. Please call us at 802-846-8177 or 800-722-7708 to schedule an appointment. We look forward to hearing from you soon
Account Balance Notification Hello this is Pediatric Associates calling. Our records indicate that your account is more than 60 days overdue. Please call our office at 802-846-8177 or 800-722-7708 to arrange payment today. Thank you!

Responding to a Phone Reminder: If a person answers the phone and hears the message live, they will have an opportunity to press numbers to confirm the appointment, repeat the message, or cancel the appointment. If an answering machine or voicemail answers the phone, an additional message will play instead: “If you need to cancel or reschedule this appointment, please call us during normal business hours at 802-846-8177 or 800-722-7708.”

E-Mails

When the patient has indicated they would prefer email communication, or your notification is configured for email delivery, this is the email template for an appointment reminder:

Responding to an E-Mail Reminder: Email reminders include a confirmation button. There is no cancellation option for emails at this time; families will need to call the office to cancel a scheduled appointment.

The email template for a Due for a Visit notification differs slightly.

The email template for an account balance notification is similar:

Practice Location: If you have more than one location, you can indicate a different practice phone number in the body of the message. You can only show one official practice address on the right-hand panel, however, unless you have more than one TeleVox account. If you need to show different addresses, work with PCC Support to discuss your options.

Text Messages

When the patient has indicated they would prefer text message communication, or your notification is configured for text message delivery, this is the standard text message for an appointment reminder:

Responding to a Text Reminder: Text messages include an option for the recipient to text back and confirm or cancel the appointment. 

A “Due for a Visit” notification would read, “Pediatric Associates: Johnny is due for a Well Visit. Please contact us at 802-846-8177 or 800-722-7708 to schedule an appt.”

Which Notification Delivery Method is Used?

When your notification is processed, PCC uses TeleVox to contact your patients by phone, email, or text message. How does it know which delivery method to use?

Default Settings

By default, PCC looks for a patient confidential communication preference. If the patient’s preference is set to “No Preference”, then PCC will use the first available phone number in the patient’s Home account. Alternatively, the default delivery method behavior can be defined in the Patient Notification Center section of your practice’s configuration. Contact PCC Support.

Your office can collect a patient’s phone, email, or text message preference in the Confidential Communication Preference section during patient checkin or in the Demographics section of the patient’s chart in PCC EHR.

Custom Delivery Method

When you create or edit a notification, you can also specify the preferred and alternate delivery methods. For example, you could tell your PCC system to send TeleVox instructions to text message the Home account’s cell phone number, if available, and otherwise to call the home number.

Notification Features and Options

Once your registration is complete and PCC Support has activated the features on your system, you are ready to create your first patient notification.

General Options

  • One-Time, or Recurring?: If you wish, you can use the Patient Notification Center to create a single, one-time notification to patients, based on their upcoming visits. Or, you can design a recurring, “always active” notification.

    Most offices interested in using notifications for appointment reminders will want to create a recurring, daily notification. Then, all patients who meet your criteria and have upcoming appointments will receive a reminder. If an appointment reminder is not recurring or not daily, some patients will not receive reminders.

  • Recurring Notifications Must Expire: When your practice sets up a recurring notification, PCC Support will configure an expiration date for that notification. You can set the date to several years or months into the future. Later, you can edit and extend the expiration date at any time. When your recurring notification is about to expire, your PCC system will send an email message to a designated system administrator user on your PCC system. On the last day before a notification expires, your system will also open a support sheet with your PCC account team. Contact PCC Support for help configuring your practice’s administrator user.

  • What Patients to Include?: You can limit appointment notifications to certain visit reasons, physicians, or other criteria. For example, you may decide to only send reminders for Well visits, because missed Well visits are more costly and disruptive to your practice’s schedule. Or, you may want to send appointment reminders for some physicians but not for others.

  • What Patients to Exclude?: You can indicate which patient or account status flags should cause the patient to be excluded from receiving notification messages. By default, for example, PCC’s notify system will exclude patients who have status flags that are configured to indicate an inactive patient. PCC Support can configure your notifications to include or exclude patients based on any status flag.

  • What Delivery Methods to Use?: As described above and in the how-to procedures, you can specify the preferred delivery method (email, phone, or text message) and the preferred data source (Home account, Billing account, or patient chart record), for each notification.

Appointment Reminder Options

What kind of appointment reminders do you wish to send? Before you jump in, your office should consider the following useful options and work with PCC Support to configure your settings appropriately.

  • Note: All appointment reminders include the date, time, and location of the appointment. You can elect to include or exclude the scheduled physician’s name in the reminder.

  • How Early to Remind?: When creating an appointment reminder notification, you can decide how many days in advance to send appointment notification reminders to the patients.

Cancellation and Confirm Features Between the Appointment Book and PCC’s Notify Service

When you use PCC’s Notify service to send families notifications about upcoming appointments, your practice can optionally allow the family to cancel their appointment from the notification phone call, email or text message.

You have two ways of handling cancellation responses from families:

  • Your practice can review a report of which families canceled appointments and then manually cancel them in the Appointment Book (or call the family to reschedule).
  • Or your practice can configure PCC so that an appointment will be cancelled when the family selects the cancel option or texts “No” to the confirmation message. When a family cancels an appointment, that slot will be available for your practice to schedule right away in PCC, without any intervention.

To review these options and optimize how PCC’s Notify service works with your PCC Appointment Book, get in touch with PCC Support.

“Due for a Visit” Options

  • Include the Recall Reason, or Not?: Your Due for a Visit notification can include a recall reason, such as “Well Visit”, or not. Recall Reasons are a pre-defined list designed by PCC and TeleVox to preserve patient confidentiality:

    • Well Visit
    • Follow Up Visit
    • Medication Check
    • Vaccination
    • Flu Vaccination
  • Recall Criteria: The Patient Notification Center uses the same criteria options as the Patient Recaller. When creating a Due for a Visit notification, you can remove patients who already have a scheduled appointment, limit the age range, or divide recalls up by primary care physician, geographical region, or other criteria.

Account Balance Options

  • What Balance Range Triggers a Notification?: Your Account Balance notification can be limited to balances over $5.00, for example, or any amount you specify.

  • What Aging Categories?: Will you send notifications as soon as balances are more than 30 days overdue, or wait for 60? 90? The Patient Notification Center uses the same criteria options as the Patient Recaller. When creating a Due for a Visit notification, you can remove patients who already have a scheduled appointment, limit the age range, or divide recalls up by primary care physician, geographical region, or other criteria.

  • Restrict By Flag: You can use account status flags to ensure that certain accounts do not receive notifications, or set up a specialized notification that is only sent to accounts with certain status flags..

Other Considerations and Useful Options

Here are some considerations and options to consider when implementing your practice’s automated notification plan:

  • How Does a Family Opt Out?: Based on your criteria, your PCC systems will call or text all families. They will always get a welcome message with instructions about how to opt out before they receive their first reminder. If a family account does not wish to receive messages to their cell phone, they can opt out at any time by sending STOP to 622-622. If someone accidentally “stops” receiving messages from your practice and wants to start receiving them again, they can send your practice’s ORGKEY to 622-622 to opt back in.

  • Switching Phone Carriers Requires Family to Opt Back In: If a patient or parent changes to a different phone carrier, their number may no longer be recognized. While only the cell user knows when they make a carrier change, you will see a line in your notification logs stating that the message was undelivered due to a carrier error. To opt back in, the family can text your practice’s ORGKEY to 622-622.

  • Written Consent to Call or Text: Under the FCC TCPA regulations, there are some legal considerations with regard to calls or texts sent to a cell phone using an autodialer. Because the legal details can be tricky to follow and open to legal interpretation, PCC recommends that your practice gets written consent to call or text. An easy way to do this would be to add a small blurb to your practice’s policy or demographic form. For more information and sample text, read Best Practices for Use of Automated Communications. You may also wish to consult your practice’s legal counsel, as PCC can not provide legal advice.

  • Family Messaging Options: The Patient Notification Center can use TeleVox to automatically delivery reminder messages to all patients with scheduled appointments. But if a family has more than one sibling scheduled for an appointment on the same day, they might receive two messages in a row to the same phone number. Optionally, you can call PCC Support and ask for the “Family Messaging” option. We will adjust TeleVox settings so families will only get one message a day, a reminder for the first patient. All other patients with appointments later that day for that family will not receive a reminder.

  • New Clinicians?: When you add a new physician or other scheduling provider to your practice, be sure and contact PCC Support so they can be added to your configuration for the Patient Notification Center.

  • Area Codes are Required: For telephone notifications to work, the numbers in your patient and family records must be 10 digits long. If an account only lists a seven-digit phone number, the Patient Notification Center will not send the information to Televox.

  • Patient Confidential Communication Preference Can Stop Delivery: The patient’s confidential communication preference is the first default delivery method. If a patient has a mailing address or invalid entry listed, your PCC system will honor that request and TeleVox will not deliver the notification to any alternate delivery method. Otherwise, our PCC system will use any available alternate delivery method configured for each notification. You can override this behavior by configuring a notification so that it goes directly to a Billing account or Home account delivery method, or you can change your practice’s defaults in the Patient Notification Center section of your practice’s configuration.

  • FCC Auto-Call Guidelines: There must be an appointment or other clinical reason to contact a patient. You can not use auto-call features or the Patient Notification Center for marketing purposes.

  • From and Reply-To addresses: Email notifications are created and sent by Televox and therefore use televox.com email addresses in the “From” and “Reply-To” fields. These addresses cannot be changed or hidden.

Create a Notification

PCC Support will set up your automatic notifications based on your preferred criteria. You can notify patients about upcoming balances, overdue well visits, and more.

Contact PCC Sales to learn about signing up for the notification service. Then, when you are ready to set up a recurring notification or you need to make changes to an existing notification, contact PCC Support.


Review the Notification Log and Canceled Appointments

Your PCC system records details whenever the Patient Notification Center prepares and sends a batch of patient notifications. If you use patient response features, PCC also logs whether the patient confirmed or canceled the appointment when they received an appointment notification.

Use the Activity Log to review your practice’s log of notifications, research why a notification was not sent, review any responses to appointment notifications, and see a list of all notifications for a specific patient or family.

First, run the Patient Notification Center from the Practice Management window.

Next, press F8 – View Log to view the Activity Log.


The Activity Log displays a list of every time PCC prepared and sent notifications, sorted by date. You can quickly see all of the notification batches that were sent successfully, and review how many patient notifications were sent or not sent to the TeleVox system.

Review the Log and Status Results

Use the arrow keys to select a notification and press F1 – Show Messages to review the status of each message inside the notification batch.


Messages are sorted into delivery categories, such as “Phone Messages” and “E-Mail Messages”.

Within each category, cancelations always appear first, at the top, followed by notifications that were delivered or have other statuses, such as “Delivered – Answered and Hung Up”.

Review Responses for a Specific Patient or Account

You can use the Patient or Account search features to quickly find all responses for a particular family or patient. Open the log and press F6 – Patient Search or F7 – Account Search.

After finding a patient or account, you can see all notifications and any confirmations or other responses.

If a patient doesn’t show up for an appointment, for example, you could use the search tools to see if they received or responded to a notification.

Review Notification Details

Select a notification and press F3 – Review Details to review the settings of the notification. If you are unsure why certain patients were or were not included in the notification, it may help to review those settings.

Automatic Cancelation

PCC can automatically cancel a patient’s appointment whenever a cancelation request is received.

Contact PCC Support for help implementing automatic cancelation when patients respond to an appointment reminder message. The cancelation responses will appear in the log as well as in the patient’s appointment history.

Exclude Patients from Communications

August 3, 2015/in Generate Front Desk, Scheduling, Demographic, and Patient Portal Reports, Contact, Remind, and Notify Patients and Families Edit Patient and Family Information /by Douglas Beagley

Patients and families may request that you do not call them or send them e-mails with appointment reminders or recall reminders. PCC’s tools for contacting families have some automated methods for this, such as respecting the “STOP” command for text messages. Your office can also use status flags to keep track of patients and families that do not want to receive reminders.

Read the procedure below to learn how to use flags to ensure that patients do not receive unwanted auto-calls or mailings.

Create “Do Not Contact” Status Flags

Use the Tables tool in PCC EHR to create flags for patients or accounts that do not wish to receive reminders.

For example, you might create a “Do Not Notify” flag in the Patient Flags and/or Account Flags tables. You could also create more reason specific flags.

Add Flags to Patients and Accounts

Whenever a patient or family requests that they no longer receive notifications or recall announcements, add the appropriate flag in the Demographics section of the patient’s chart.

You can also update flags during the patient checkin process, or anywhere that the demographics components appear.

Exclude By Status Flags When Running Reports and Using PCC’s Contact Tools

In the PCC EHR Report Library or other reporting or recall tool, use the criteria options to exclude by designated patient and account flags when you send messages.

If you use a third party notification service (TeleVox), work with PCC Support to update your criteria.

PCC’s Tools to Remind, Recall, and Contact Patients

August 3, 2015/in Get Started Contact, Remind, and Notify Patients and Families /by Douglas Beagley

PCC software has built in tools for contacting patients and families by text, e-mail, or form letter. You can use PCC reports to identify patients who are overdue for well visits, vaccines, or med checks. The tables below show PCC’s recommended tools for regular outreach.

Every practice’s needs are different. As a pediatric practice owner or practice manager, you won’t necessarily use all of these strategies on a certain schedule. Instead, you can evaluate which tools will help you address the patient recall that your practice needs to focus on. Contact PCC Support at any time to discuss your particular needs, or if you’d like help finding a report or designing a custom recall strategy.

To learn more about why your practice needs to focus on patient recall, read Why and How Pediatric Practices Should Launch a Recall Initiative Today.

Patient Recall Resources

PCC Tool Purpose Where to Find
Find and Recall Patients Who Are Overdue for Vaccines Learn strategies for vaccine recall Report Library and Practice Vitals Dashboard
Find and Recall Patients Who Are Overdue for Well or Chronic Condition Visits Learn strategies for well visit and chronic condition visit recall Report Library
UC Course: Recall Who and When? (presentation slides and video) Learn how to know which patients you need to recall, which reports to use, and the tools that PCC offers to assist. Learn.pcc.com

Patient Communication Tools

PCC Tool Purpose Where to Find
Broadcast Messaging (article and video) Send batch messages to patients and families Report Library
Receive and Respond to Patient Portal Messages Communicate with patients and families through the patient portal PCC EHR and PCC’s Patient Portal (My Kids Chart)
Send a Message Directly to a Patient or Family (article and video) Communicate with patients and families via one-way SMS Send Text feature in PCC EHR
Third Party Patient Recall Specialists Export a list of patients for use with a phone vendor service, such as TeleVox, VoiceGate, PhoneTree, MedBuddy, and more. Contact PCC to discuss your options.

Explore Patient Communication Options

Not sure which communication method to use when? Explore your options below and read the linked article to learn how to use each communication option.

Send Batch Messages to Lists of Patients and Families

PCC EHR’s Broadcast Messaging feature can send a message via email or text (SMS) message to a list of patients generated through the Report Library.

Reports within the Report Library’s Patient Recall category each have the option of sending a message to the resulting list of patients. Select your options to build exactly the list of accounts you need, run the report, and click “Export” to send a message via text or email to everyone on the list.

For more detailed information, read the Send Broadcast Messages to Patients and Families article.

Exchange Messages Via PCC’s Patient Portal

When viewing a patient’s chart, use “Add Portal Message” in PCC EHR’s Edit menu to send a message to a patient portal user associated with that patient. They can read and reply to your message within the portal, or send you a new message themselves.

For more information read Patient Portal Messaging.

Send a Text Directly to a Patient or Family

Use PCC EHR’s Send Text tool to send out a note, contact information, telemedicine link, or other short message via SMS Text to any number associated with a patient, directly from the EHR.

  • From the Schedule Screen: From the schedule screen, select an appointment and click “Send Text” to send them a text message.

  • From a Patient's Chart: Open any patient’s chart and then select “Send Text” from the Edit menu.

For more information, read Send a Text Message Directly to a Patient or Family.

Create a List of Patients for Preventive Care Recall and Chronic Condition Recall

The Preventive Care Recall and Chronic Condition Recall reports are the easiest way to recall patients in PCC EHR. They enable you to run effective recalls for preventive care as well as chronic conditions.

The Patient Notification Center

Your PCC system includes the Patient Notification Center (notify), an under-the-hood software service that automatically creates lists of patients and families and sends automated messages through a third-party integration provider (Televox, formerly known as Intrado). The Patient Notification Center supports appointment reminders, “Due for a Visit” notifications, and account balance notifications.

Contact PCC Support for help setting up these notifications.

To learn more, read Create Recurring Notifications for Patients and Families.

TeleVox, VoiceGate, PhoneTree, MedBuddy and Other Contact Systems

PCC can help create a custom workflow to export a list of patients for use with a phone vendor service. Contact PCC Support to learn more.

Use Contract Fee Schedules (Allowables) to Monitor Reimbursement

August 3, 2015/in Add and Configure Insurance Companies Previous System Tools /by Douglas Beagley

You can use PCC to track your payor contract fee schedule amounts, also known as “allowables” or the “allowed amount” for each procedure. Then, when autoposting insurance payments, you can review any responses on the ERA that did not match the fee schedule. When you manually post insurance payments, you can see whether or not the payment amount you enter matches the fee schedule. Later, you can report on whether or not payors are honoring their contracts.

Alternatives: If you wish to track and evaluate insurance reimbursement levels without the labor of maintaining your contract fee schedules in PCC software, you can accomplish this with other PCC reports. Contact PCC support for help finding reports to evaluate your insurance payment rates.

Configure and Maintain Your Contract Fee Schedules

Read the sections below to learn how to create, clone, edit, and assign a contract fee schedule in PCC.

Create a New Contract Fee Schedule

Follow the procedure below to create a new contract fee schedule.

Run the Contract Schedule Editor (allowedit)

Open allowedit in the Practice Management window.

Press F5 – Add New Schedule to Create a New Schedule

Name Your New Schedule

Enter a name in the Schedule name field. Use a unique name based on the contract.

Make a Mistake?: Don’t worry if you make a mistake naming your fee schedule. You can press F3 – Change Name from the main allowedit screen to rename a fee schedule.

Press F1 – Process to Save Your Schedule

Begin Adding Fees to Your Schedule

Use the up and down arrow keys to select your new schedule. Then use the function keys to add fee amounts or perform other functions. See the procedures below for more information.

Clone an Existing Contract Fee Schedule

When you have a new contract with a payer, you may wish to clone an existing contract fee schedule and make changes to it, keeping the old fee schedule in place until you make the transition. Follow the procedure below to clone a contract fee schedule.

Select Original Schedule

Use the arrow keys to select the original contract fee schedule in allowedit.

Press F6 – Clone Schedule

Enter a New Name, Optionally Set Start Date

Enter a name for your schedule and decide whether all procedures should begin with a new “start” date, such as a new contract date, or if dates from the original schedule should be copied.

Press F1 – Save

Remember to Assign: Once you have cloned an old schedule, you can begin working on the clone and making changes. Your new schedule will not affect any claim result posting until after you assign it to insurance plans. See the sections below to learn how to assign a schedule to a plan.

Add Contract Fee Amount By Procedure Code

You can add or edit contract fee amounts for a specific procedure code. Follow the procedure below to see an example.

Run the Contract Schedule Editor (allowedit) and Select Your Fee Schedule

You can find the Contract Fee Schedule Editor in the Insurance Configuration window. You can also type allowedit at a command prompt.

Use the arrow keys to select the contract schedule to which you wish to add fees.

Press F1 – Edit By CPT

Press F1 to edit the schedule.

Wait While RBRVU is Calculated

There will be a brief pause as Partner builds an RBRVU value list.

Enter a Procedure Code and Press Enter

Enter a billing code in the Code field. You may have several related codes that also need to be set. Enter the base code.

Review Procedures and Existing Values

Every matching procedure for the code you entered will appear on the screen. Previous contractual amounts may appear along with activation dates.

Adjust Calculations and Make Other Changes: Using the function keys at the bottom of the screen, you can change the year and percentage of the RVU calculation and recalculate, sort the list of procedures in different ways, jump down to a specific billing code, hide or show the former contract amounts, and edit historical fees. You can also press Page Down or Page Up to scroll through the list of procedures.

Enter New Fee Amounts and Specify Effective Date

In the fields provided, enter the new Contract Fee Amounts and the Effective Start Date of the amount.

Setting the Date: If you are entering contractual amounts that pertain to past dates of service, be sure and back-date the amounts to the date the contract became effective.

Automated Entry: After you add the first amount and date for the first item, allowedit will copy the information to the fields for the other billing codes. Be sure and change any code entries that should not have the same amount and date.

Press F1 – Save and Restart

Press F1 to save your changes.

Continue to the Next Code or Press F12 to Quit

Enter another billing code to continue working, or press F12 to return to the Contract Schedule menu.

Edit Contract Fee Amounts for All Codes

Follow the procedure below to edit a contract fee schedule and enter fee amounts for all codes based on a percentage of Medicaid’s RBRVU value.

Run the Contract Schedule Editor (allowedit) and Select Your Fee Schedule

Use the arrow keys to select the contract schedule to which you wish to add fees.

Press F2 – Edit Full Schedule

Wait While RBRVU is Calculated

There will be a brief pause as Partner builds an RBRVU value list.

Review Procedures and Existing Values

Every procedure in your Procedures table will appear on the screen. Previous contractual amounts may appear along with activation dates.

Adjust Calculations and Make Other Changes: Using the function keys at the bottom of the screen, you can change the year and percentage of the RVU calculation and recalculate, sort the list of procedures in different ways, jump down to a specific billing code, hide or show the former contract amounts, and edit historical fees. You can also press Page Down or Page Up to scroll through the list of procedures.

Enter New Fee Amounts and Dates

In the fields provided, enter the new Contractual Amounts and the Effective Start Date of the contract.

Setting the Date: If you are entering contractual amounts that pertain to past dates of service, be sure and back-date the amounts to the date the contract became effective.

Press F1 – Save

When you are finished entering fee amounts, press F1 to save your changes and return to the list of schedules.

Use the RBRVU and BNA Calculations

The Update Schedule screen displays a column containing an estimated fee amount.

The amount is a calculation based on a percentage of Medicare’s reimbursement with or without the Budget Neutrality Adjustment.
You can change three factors that determine what amounts will appear:

  • Medicare Year: If the contract you are entering is based on a specific Medicare year or you wish to compare your contractual fees to a specific Medicare year, enter the year at the top and press F3 – Recalculate RVU.

  • Percentage: If you are creating a contract based on a percentage of Medicare’s reimbursement, edit the percentage column and press F3.

  • Budget Neutrality Adjustment: If you need to see fee amounts with the BNA adjustment applied, set the BNA field to Yes and press F3.

You can learn more about RBRVUs and using Medicare reimbursement by visiting PCC.com or attending a PCC Users Conference.

Assign Contract Fee Schedule to Insurance Plans

After creating a Contract Fee Schedule and entering the allowable amounts, you must assign the schedule to insurance plans.

Select the Schedule in allowedit

Use the arrow keys to pick the contract fee schedule you wish to assign.

Press F4 – Assign Schedule

Review the Existing Assigned Insurance Plans

If the schedule is already assigned to any insurance plans, they will appear on the first Schedule Assignment screen.

Press Page Down and Page Up to review the list.

Press F4 – Assign

Select Additional Plans

Use the arrow keys to find plans and press F2 – Select to choose groups or individual plans.

Filter For Easy Selection: Use F5 – List by Group and F6 – List by Pattern to find plans more easily and select them.

Press F1 – Save

Press F1 to confirm your selection and return to the contract fee schedule’s list of plans.

Post Payments, Review Values

Manually post an insurance payment to test your contract fee schedule.

Read Manually Post Insurance Payments and Adjustments to learn more.

Assign Allowable Schedules in the Tables Tool: When you assign a contract fee schedule to a plan or group of plans, allowedit places the name of the schedule into each insurance plan in your practice’s Insurance Plans table. When your practice clones an insurance plan to create new plans, the cloned plan will have the same allowable schedule.

Compare Payor’s Payment to Your Contract Fee Schedule

When you autopost insurance payments in the Electronic Remittance Advice tool, you can filter for responses that did not meet the allowable amount when you review the processed ERA.

When you autopost an ERA, PCC EHR posts all payments and adjustments regardless of the allowed amounts. It then indicates the number of charge responses that were greater or less than the allowed amount, based on your contract fee schedule, in the Special Cases section of the Autopost Processing Summary. You can filter the ERA by special cases to review payor responses that do not match your contract fee schedule. See Post Insurance Payments and Read ERA 835s from Payors to learn more.

When you manually post insurance payments and adjustments, you can see the total “Covered Amount” based on the payment and adjustment. If your practice has configured and assigned a contract fee schedule for a procedure for the responsible payor, you can review the contract rate in the right-most column.

You can quickly compare the “Covered Amount” with your practice’s “Negotiated Rate”. See Post Insurance Payments to learn more.

Report on Payor Payment vs Negotiated Contract Rate

How can you tell when payors repeatedly fail to pay in accordance with your contract fee schedules? Are you getting paid correctly, according to your negotiated rates?

When preparing for payer contract negotiation or planning for potential insurance takebacks, you can reference two different allowables reports in the Report Library. These reports compare payments received against the contract fee schedule to evaluate payer underpayment and overpayment during a given period of time.

The default versions for both of these reports are run by payment posting date and are sorted by the insurance group that the patient had at the time of service. Each row in the report represents an insurance payment. Personal payments do not display in these reports.

Evaluate Overpayments

Run the Allowable Overpayments by Insurance Group report to review insurance payments that were above contracted amounts in order to identify potential takebacks or fee schedules that need to be updated.

Positive numbers indicate an overpayment, and could signal an upcoming insurance takeback.

Evaluate Underpayments

Run the Allowable Underpayments by Insurance Group report to review insurance payments that were below contracted amounts in order to identify payer errors.

Negative numbers are designated by parentheses and indicate underpayments. Your practice may wish to follow up with the insurance company about underpayment trends.

20,000 Row Limit: Reports in the Report Library are currently limited to 20,000 rows. If your output appears to be exactly 20,000 rows long, it may not contain all of the information that you are looking for. If this occurs, return to the Criteria screen and limit your report criteria until your output rows are under 20,000. If all of your current criteria settings must be included in your report but you are still hitting the 20,000-row limit, contact PCC Support for help creating a specialized report.

Customize Underpayment and Overpayment Reports

You can add the payment transaction date, allowable schedule, and other criteria, when you customize these reports.

To add the date of service (the day the patient came in to the office) to your report output, select “Linked Charge Transaction Date” when customizing the report.


For more information on customizing reports, read Create a Custom Report.

For more information about working with reports in the report library, read Run Reports in the Report Library.

To learn how to limit access to these reports, read Restrict Access to Reports in the Report Library.

Add and Configure Immunizations in PCC EHR

August 3, 2015/in Configure Other PCC EHR Features, Immunizations Configure PCC EHR /by Douglas Beagley

When a new immunization becomes available, you can add it to your list of procedures and make configuration changes so you can easily chart, order, bill, and track the immunization at your practice. Read below to learn how. In addition to adding a vaccine that you administer, you can use the steps below to add vaccines that your practice will track but will never administer. You can also add medication procedures performed and billed by your office.

Contact PCC Support: PCC Support performs initial setup for all immunizations at a practice, and they can walk you through the process below and help you with any step.

COVID-19 Vaccines: For a brief COVID-19 version of these instructions, read COVID-19 Vaccines in PCC EHR: Configure, Order, Administer, and Track.

Add or Update an Immunization on Your PCC System

Open Your Practice’s Procedures Table

Open the Procedures table in the Tables tool.


Edit or Clone an Immunization Procedure

Use the search field or sort by a column header to find an existing immunization procedure. Double-click to edit an entry, or select an entry and click “Clone” to add a new entry.

Update an Existing Entry or Add a New Entry: If you are updating a price or correcting a code or medication information for a procedure, you can edit an existing entry. However, if you have switched suppliers for a vaccine, or are now administering a different dose, PCC recommends you clone your existing procedure to create a new one with the same procedure code. For example, a new manufacturer may have a different NDC code and your records should reflect which NDC code was on the medication you administered.

How Do I Delete a Medication We No Longer Administer?: Your practice should never delete or overwrite an old procedure as this will affect historical records. Instead, your practice may want to retire an immunization, or render it no longer “orderable,” so that you do not see it when you order or administer shots. To learn how to retire an immunization, read Retire an Immunization So It Can No Longer Be Ordered.

Enter Basic Information For the Immunization

Enter the immunization’s name, procedure group, type of service, accounting type, and units. Keep in mind that this is the vaccine or medication procedure and that administration is usually billed as a separate procedure.

For a reference to these fields, read Edit Your Practice’s Procedures, Codes, Adjustments, and Prices.

  • Procedure Name: If you use more than one manufacturer or brand names for a vaccine, PCC recommends you create separate Procedure table entries with unique names so your office can select the correct version, such as “Rotavirus Vaccine (Rotateq)” or “COVID-19 (Pfizer)”.

  • Units: In almost all situations, enter one (1) unit. You administer and bill for a single vaccine. If multiple shots are given during a single encounter, you can select that at time of service on the Bill screen. If you always administer two or more units of a medication, then you could indicate that in the Units field and also change the Procedure’s name to “Drug Name (2 Units)”, for example.

Enter NDC and Dosage Information

Next, enter the NDC and dosage information for the immunization.

NDC and dosage information in the image above are for illustration purposes only.

  • NDC: Enter the National Drug Code for the immunization or medication. The National Drug Code is an 11-digit number used to identify the vaccine or medication you administer. The first five digits of an NDC refer to the Labeler or Manufacturer. The next four digits indicate the Product Code. The last two digits indicate the Package Code. Not all commercial payers require NDC information on the claim, but it is required for most Medicaid plans. You can check the label on the vaccine or medication to find the NDC. You can also cross reference the National Drug Code Library. The NDC code standard supports either 10 or 11 digits, however claims require 11-digit NDCs, and PCC’s NDC field will automatically add 0s in order to extend a 10-digit code.

  • From the Vial, Not the Box: You should enter the NDC code printed on the smallest administered dose, such as the specific tube, vial, or pouch that contains the vaccine or medication. This is sometimes referred to as the “use” NDC. Do not enter the NDC code printed on a box or carton that contains more than one dose, often referred to as the “sale” NDC.


    In the example above, you can see that the last two digits of the vial you administer are different from the last two digits on the box. You should enter the NDC code from the vial, not the box.

  • Dose Amount and Dose Units: Enter the dose amount and dose units found on the vial, pouch, or tube that you administer. For example, the Pfizer COVID-19 vaccine is administered as 0.3 mL, so you would enter “0.3” and “mL”. NDC codes are unique to each dosage, but a clinician might administer only part of the full package contents as indicated by the NDC code, such as in the case of a multi-dose vial.

  • TriCare and Other Special Coding Requirements: Some payers may require a different value in the Dose Amount and Dose Units fields. For example, some billers have reported that TriCare requires “1” and “UN” to indicate one unit in these fields for Hib, DTaP-Hib-IPV, MMR, and Varicella. If a payer has their own rules, you can create new Procedure table entries to accommodate those rules for billing.

Enter Procedure Billing Codes and Prices

Enter the procedure code or codes for the immunization and enter your practice’s price. You can click “Duplicate Code (A)” and “Duplicate Price (A)” to copy the first value to all schedules.

PCC does not distribute or publish billing codes or make pricing recommendations; the examples in the image above are for illustrative purposes only.

  • Procedure Code or CPT: Enter a billing procedure code for the vaccine or medication. Under normal situations, enter the same code for all schedules. PCC supports optional schedules due to deprecated “local codes”, which are no longer part of the claim standard. If your practice has a schedule specifically configured for Medicaid billing, and your state Medicaid program requires a modifier (such as -SL), you can enter the full code + modifier in the field for that schedule. Or you can clone the procedure to create a new entry specifically for Medicaid billing.

  • Price: Enter a price for the procedure in the fields for each schedule. A procedure’s price should be identical in all schedule fields, except where your practice uses a different fee schedule. For example, some pediatric practices use a fee schedule for Medicaid plans, where they enter a $0 (or a reduced price, such as in the case of Oregon) for immunizations, ensuring that VFC procedures are billed correctly. Read below for more details.

If your practice needs a separate code or fee schedule, work with PCC Support to ensure that the correct insurance policies are configured to use the custom schedule.

Save

Click “Save” to save your changes.

Contact PCC Support

PCC Support will add the immunization to your Immunization and Disease table and underlying configuration for immunization tools in PCC EHR. Contact PCC Support at support@pcc.com or 802-846-8177 or 800-722-7708.

Configure Your System to Display, Print, and Submit the Immunization to Registries

PCC Support will complete these configuration steps for you. Contact them at support@pcc.com or 802-846-8177 or 800-722-7708.

After PCC Support adds the new vaccine to your PCC system’s underlying configuration, they will work with you to test your configuration and to make adjustments to your printable immunization school form(s).

VFC (Vaccines for Children) and Other Free or Reduced Cost Vaccine Programs

If your practice administers VFC immunizations or other free or reduced vaccines, PCC Support will work with you to configure your immunizations so they are not billed at your usual price.

Typically, PCC sets up a price schedule for Medicaid insurance plans (for example, Schedule E or Schedule D). You can then enter $0.00, or your state’s VFC rate (Oregon, for example, reimburses 21.96 per vaccine) into that price schedule for your immunization procedures. If your practice sees patients from two different states with different VFC rates, we can use two different schedules to enter a price for each.

PCC Support will adjust your billing configuration so appropriate policies will use the correct price schedule. Then, when your practice posts charges for an immunization, PCC’s billing system will check the patient’s policy and use the appropriate schedule’s price, and both the account record and your practice’s claims will reflect the correct pricing for VFC immunizations.

Your state may also have special requirements for immunization administration fees for VFC. Some practices do not bill an administration code for VFC, others may use a mandated price. You can use the same schedule to indicate the correct price for those administrative procedures.

While setting up a price schedule is the most common solution for configuring VFC immunizations for billing, there are other solutions that you can explore with PCC Support. For example, some practices create unique procedures for VFC immunizations (using the same billing code), and some practices set up distinct orders in PCC EHR.

What About VFC Immunization Orders, Reviewing VFC Status for Patients, and Managing VFC Lots in my Fridge?: Practices keep their VFC and standard vaccine lots separate in their refrigerator and track them separately in PCC EHR’s immunization lot manager. At the time of service, clinicians can review and set a patient’s VFC status and select an appropriate immunization lot. For more information, read Review, Order, and Administer Immunizations and Manage Immunization Lots and Track Vaccine Inventory.

Add the -SL Modifier to VFC Immunizations

If your medicaid payers require the -SL modifier for VFC immunizations (-SL indicates a “State Supplied” immunization), you can enter that -SL modifier into the billing code field for a custom schedule in the Procedure Table.

Work with PCC Support to ensure that the correct policies are using the correct code schedule for claim processing.

Note that PCC’s billing system uses code schedules only when claims are generated. That means the -SL modifier will not appear elsewhere in the account and patient billing records. As an alternative, your practice could clone each immunization procedure and create a -SL version of the procedure. Your practice would then select the VFC procedure for qualifying patients.

Should I Use $0.00, $0.01, or $0.10 for VFC Immunizations?

If your state’s VFC rate is $0.00, then you should set your VFC immunization procedure price or price schedule to $0.00.

In the past, some pediatric practices have encountered problems with $0.00 charges with some payers. If you a payer denies or fails to respond to a $0.00 VFC immunization on a claim, or denies the administration fee (for example), PCC recommends you work with that payer to resolve the issue. This is an incorrect implementation of the claim standard; $0.00 charges should be processed like any other item on a claim. In some cases, this has turned out to be a missing required code modifier, for example.

If a payor informs you in writing that they require a $0.01 or $0.10 charge for VFC immunizations on claims, you can implement this using a price schedule for the immunization as described above. Work with PCC Support to ensure that the appropriate insurance plans are configured to use the custom fee schedule in the Procedure Table.

Configure Which Immunization Orders Appear on Chart Note Protocols

Use the Protocol Configuration tool to add immunizations to the Immunizations component for specific chart note protocols.

The Immunizations component can appear on any chart note, and a clinician can always search and find any immunization order. You can save clinicians’ time by putting specific immunizations right on your practice’s chart notes, so they will be available with a single click. For example, you can add the age-appropriate immunizations to chart note protocols for each well visit. Then a user could more easily click to order each immunization for that visit, instead of having to type in the shots they need.

Read the Add Age-Appropriate Immunizations to a Chart Note Protocol to learn more.

Map Z23 and Billing Procedure Codes to an Immunization Order

When a clinician clicks “Order” next to a vaccine (or a medication procedure), PCC EHR can automatically place diagnoses and procedure billing codes onto the encounter for billing. When you add a new vaccine, use the Billing Configuration tool to map precisely which codes should be triggered by that order.


For most immunization orders, add the Z23 diagnosis code and the billing procedure that you added to your Procedures table.

Read the Configure Order Billing, Diagnoses, and the Bill Window to learn more.

Customize How Immunizations Appear in the Patient’s Chart

Use the Immunization Configuration tool in PCC EHR to configure the order that immunizations appear in a patient’s Immunization History. Use the same tool to set whether or not the immunization will always appear in a patient’s chart or will only appear if they have had a dose.


Click and drag to rearrange how immunizations appear in a patient’s chart. Click the “Display” checkbox next to all immunizations you would like to appear in a patient’s Immunization History, even if they have never received a dose.

Office-Wide Configuration: When you change your Immunization History layout, it affects all users and all patient charts.

All Immunization Records Will Appear: In a patient’s chart, the Immunization History will display all immunizations that a patient has received. You can also configure an immunization to appear on every patient’s record, even if they have never received a dose. For example, since all patients should receive an IPV, most practices select “Display” next to “IPV” in the Immunization Configuration tool. In contrast, a practice might sometimes administer a cholera vaccine, but would only need it to appear in the patient’s record if a patient received it. They therefore would not check “Display” next to Cholera.

Edit Immunizations or Add Combination Vaccines?: The list of available immunizations in PCC EHR comes from your Procedures table, found in the Tables tool in PCC EHR. Procedures align with entries in your practice’s Immunization /Disease table. Contact PCC Support for help editing immunizations or adding new combination vaccines.

Configure Diseases on the Immunization Record

The Diseases section of the patient’s immunization record can display dates for any of the 28 diagnoses associated with vaccine-preventable diseases, whether the patient has had the disease or has serological evidence of immunity.

Your practice can specify which of the 28 vaccine-preventable disease diagnoses should appear in the Immunization History, on patient reports, or be sent to an immunization registry.

To make changes, open the Immunization Configuration tool and select the Diseases tab.


For each of the 28 diagnoses, you can select whether or not it will appear on the patient’s immunization history, on reports, and whether or not disease immunity will be sent to an HL7 compliant immunization registry.

For example, if a patient is diagnosed with the flu, you may not want to display that in the Diseases section of the patient’s immunization record. Or, you may want HPV to appear in the chart but not appear on patient reports, such as the Patient Visit Summary. (By default, the HPV disease diagnosis will be marked to not appear on patient reports, and the immunization registry options will be disabled.)

Is Your Registry Ready?: Many immunization registries are unable to accept disease diagnoses. This feature is turned off by default, and you should work with PCC Support before turning it on for any disease diagnosis.

Customize Your Immunization School Form: You can also control whether or not the Diseases section appears on printable immunization school forms, or add it to a custom immunization form. Call PCC Support for more information.

Turn All Diseases Off and Remove the Diseases Section: If your practice does not want to display the Diseases section in the chart or on any reports, you can disable all checkboxes for all disease diagnoses.

Add Medications and Other Injectables

Your practice can use the steps in this article for medications you administer, not just immunizations.

Many pediatric practices administer albuterol, dexamethasone, diphenhydramine, ceftriaxone, decahedron, and epinephrine. You can add each of these to your Procedures table and configure an order in PCC EHR to make it easy to chart, order, bill, and track them with a single click.

Retire an Immunization So It Can No Longer Be Ordered

Your practice should never delete or overwrite an old immunization procedure in Practice Management. Doing so will affect your historical records and outstanding order.

Instead, your practice can “retire” an immunization, so that it is no longer an option (not orderable) when you order or administer vaccines. You can set immunizations as not orderable in the Tables Configuration tool.

Open the Tables Configuration Tool

Open the Configuration menu and select “Tables”.

Select the Immunization and Disease Table

Choose “Immunization/Disease” from the drop-down.


Edit the Immunization

Select the immunization that you wish to retire, then click “Edit”.

Make the Immunization Not Orderable

On the Orderable in PCC EHR line, select the “No” radio button. This will remove this immunization as an option when ordering or administering immunizations, while keeping it available for adding as historical entries.

Save and Close

Click “Save” to save your changes.


When you have updated all of the immunizations that you needed to configure, click “Back”.


If you are done in the Tables Configuration tool, click “Close”.

Manage Immunization Lots and Inventory

To learn about the Lot Manager and how to use the vaccine inventory tools in PCC EHR, read the Immunization Lots and Vaccine Inventory Management article.

Review Posted Charges In Daily Check

August 3, 2015/in Post Charges and Queue Up a Claim Previous System Tools /by Douglas Beagley

At the end of the day, after all charges are posted, you can “prove out” your cash drawer and perform reconciliation in PCC EHR Report Library. You can use tools like the Payment Reconciliation report and visit based reports.

If you need to dig deeper, use Daily Check in the Practice Management window to review details on all the charges posted for each encounter.

Use the (dailycheck) report to view all the visits posted on a single day or range of days. The report includes every diagnosis, procedure, amount charged and payment posted. If you use paper encounter forms, you can use dailycheck to compare them with the day’s postings. You can also use Daily Check to spot check whether the correct modifiers were selected for encounters you bill to certain payers. Many office managers run dailycheck every evening or early the following morning.

The dailycheck report is located in the Practice Management window.


You can select which charges to include, select a place of service, limit the report to one clinician, choose a brief or full report, sort the report by various values, and send the report to the screen, a printer, or an interactive screen.

The dailycheck output displays complete charge posting details. A total for the day (or time range) appears at the bottom of the report. The “Brief” version of the report omits codes and units and condenses linking.

“EEF” stands for “Electronic Encounter Form” and refers to the Bill screen that clinicians use to select codes and queue up charges to be posted. If you use one of the EEF options when you generate the report, you can compare posted charges with items on the Bill screen for the encounter.

Dailycheck By Location

PCC Support can configure dailycheck so it runs only for the current user’s location. When a biller in your remote office runs the report at the end of the day, the report will run in “By Location” mode.

Contact PCC Support if you wish to set up dailycheck by location for some of your users.

Edit Your Practice’s Configuration Tables

August 3, 2015/in Configure Billing Functions Configure Billing Functions /by Douglas Beagley

Tables are lists in your PCC system. For example, your practice’s system has a list of insurance policies, clinicians, visit reasons, billing procedures, and more.

Use the Tables tool in PCC EHR when you need to add a new billing code, a new insurance plan, a new payment type, or other new item to a table. You can use the Tables tool to make configuration changes that improve the accuracy of your reporting.

Video: Watch Edit Your Practice’s Configuration Tables to learn more.

Use With Caution: Making changes to your practice’s tables affects every user and can sometimes change patient records. Before making changes, consider consulting with your office’s system administrator or PCC Support at 1-800-722-1082.

Use the Tables Tool to Review and Edit a Table

Use the Tables tool to edit the underlying configuration tables used by your PCC system.

Open the Tables tool from the Configuration menu.

Select a table to review it and make changes.


As you review a table, you can search for entries and sort by columns to find items. You can click “Export” to export a comma-separated-value (CSV) file of the entire table for use in a spreadsheet. Select any entry and click “History” to review all changes to the entry.

To make changes, double-click on an entry or select an entry and click “Edit”. To add a new entry, select an existing entry and click “Clone” or click “Add”. Cloning an existing entry instead of adding one from scratch can reduce errors.


After you create or edit a table entry, click “Save”.

For more examples on how to use the Tables tool, read Edit Your Practice’s Procedures, Codes, Adjustments, and Prices and Add an Insurance Plan to Your PCC System.

Retire, Delete, or Replace a Table Entry

For most tables, you should never delete or “write over” the contents of a table entry.

Altering table entries may change historical information in patient records. If you wish to retire an entry and make it less visible, you can place a tilde (~) at the beginning of the name to sort it to the bottom of the list alphabetically. Use PCC’s other configuration and administrative tools when you need to remove an option from PCC’s software, and contact PCC Support if you need assistance.

Tables Reference

The reference below defines the user-editable tables on your PCC system. For help with diagnoses and other standardized tables, contact PCC Support.

Account Flags

Custom flags help your practice handle unique scheduling and reporting needs. You can flag family accounts that need to speak to the billing office and customize report output using flags. To learn more, see Use Custom Flags for Scheduling, Alerts, and Reporting.

Immunization/Disease

A table that lists the defined immunizations and diseases tracked by your PCC system. The only editable value in this table is the “orderable” option, which determines whether or not an immunization can be linked to an order in PCC EHR. For help with your immunization configuration, contact PCC Support.

Insurance Groups

Your practice maintains a custom list of groups of payers. These groups are used for financial reporting and do not affect claims or billing behaviors for procedures.

Insurance Plans

The list of plans that your practice bills. See Edit the Insurance Plans On Your PCC System.

Patient Flags

Custom flags help your practice handle unique scheduling and reporting needs. To learn more, see Use Custom Flags for Scheduling, Alerts, and Reporting.

Payment Types

The types of payments used when posting payments. The list also includes adjustments that result in a decreasing balance, such as an insurance adjustment.

Procedure Groups

A custom list of groups of procedures. These groups are used for financial reporting and do not affect claims or billing behaviors.

Procedures

The list of billable services that your practice performs, along with their billing codes, prices, and claim-related medication information. The list also includes adjustments that result in an increasing balance or adjustments that offset a payment, such as refunds and credit write-offs. For more details, see Edit Your Practice’s Procedures, Codes, Adjustments, and Prices.

Provider Groups

A custom list of groups of providers for reporting purposes. Under normal circumstances, this list has a 1-to-1 correspondence with clinicians at your practice.

Providers

Use your practice’s Providers table to update identifiers for your clinicians, such as their Tax ID, NPI, and taxonomy code. For more information, see Configure Clinician Billing Identifiers and Add and Configure a Clinician.

Edit the Insurance Plans On Your PCC System

August 3, 2015/in Add and Configure Insurance Companies, Bill Insurance Manage Insurance Plans on Your PCC System, Configure Billing Functions /by Douglas Beagley

When a patient or parent brings in a new insurance card, you can update their insurance policies quickly and easily. However, what if the insurance plan is entirely new to your practice? Maybe it is an existing plan, but it has a new address, copay amount, or payer ID.

Use the Tables tool in the Configuration menu in PCC EHR to update the list of plans that your practice bills. Read below to learn more.

Video: Watch Edit the Insurance Plans on Your PCC System to learn more.

Edit the Insurance Plans on Your PCC System

Read the procedure below to learn how to review and update your practice’s insurance plans.

Open the Insurance Plans Table

Open the Insurance Plans table in the Tables tool in PCC EHR.


Review Your Existing Insurance Plans

The Insurance Plans table contains all of your practice’s plans.

Double-click on an entry to open and edit the details of an insurance plan.

You can search for specific plans and sort the list by different columns. Click “Export” to download a comma-separated-value (CSV) file of the entire table for use in a spreadsheet. Click on an entry and then click “History” to see a record of all changes made to a plan.

Clone a Plan

When you’re ready to add a new plan, select an existing entry and click “Clone”.


It’s easiest to start by cloning a similar plan and then updating plan details.

Do Not Overwrite or Erase the Name of an Existing Plan: Never edit and overwrite an existing insurance plan, as this may affect your billing history. Even if a plan has been retired and replaced with a new plan, always clone it to add a new entry.

Optional: Add a New Plan

If you can’t find a plan to clone, click “Add” to create a new entry from scratch.


Then select a plan type.

Update the New Plan’s Name and Basic Information

At the top of the screen, review and update the plan’s name and other information that will be used when adding the policy to a patient’s record or submitting claims.

For ease of identification, PCC recommends including the plan’s copay in the Insurance Plan field.

Update Copay Information

Enter the plan’s default copay amount for office visits and define any unusual copay rules used for billing.

Insurance plans with a copay typically require it for office visits but not for hospital encounters and not per-procedure. Most plans do not charge a copay for well visits, which is controlled with the rules file in the Behavior section described in the next step.

Update Claim Batch and Other Billing Behaviors for the Plan

If you cloned an existing plan, this section may be filled out for you. Otherwise, select claim processing options that will control how your PCC system will handle charges and claims for this policy. Contact PCC Support for assistance.

Under most circumstances, select a claim batch that matches the payor and select the “standard” rules file, as shown. The standard rules file puts all medical procedures on the claim and charges a copay, if the plan has one, for office visit procedures. For more information on these options, see below.

Update Payor ID and Other Identifiers

If you cloned an existing plan, this section may be filled out for you. Otherwise, update the Payor ID and other identifiers used to route claims and submit eligibility requests.

The plan’s Claim Filing Indicator will be inherited from the plan you cloned or else set for you based on the plan type you selected after you clicked “Add”. For a reference to each of these options, see below.

Optional: Enter Notes

Enter notes about this specific plan for later reference.

Notes are unique per-plan table entry.

Save Your Changes

Click “Save” to save your changes and add the plan to your system.

Add the Policy to Patient Records

After you add a new plan to your PCC system, you can add it to patients’ policy records.

If you have already posted charges for an encounter, you can then edit that encounter in the Billing History, make the new plan responsible for those charges, and queue up a new claim.

Insurance Plans Reference

Read the sections below to learn more details about the Insurance Plans and Insurance Groups tables in PCC EHR. Insurance tables contain information about the insurance plans on your PCC system, which are used for billing and reporting.

How Your Practice Uses Your List of Insurance Plans and Insurance Groups

When you add a new policy to a patient’s records, you pick from your practice’s list of insurance plans.


Your practice maintains this custom list of the insurance plans that you bill. That list is kept in the Insurance Plans table in the Tables tool in PCC EHR.

When you run financial reports, the totals are often grouped by payor, with categories such as Aetna, BCBS, and Medicaid. The list of payer groups that your practice reports on is kept in the Insurance Groups table in the Tables tool in PCC EHR.

Insurance Plans Table Field Reference

Each entry in the table corresponds with a single copay amount for a plan that your practice bills. The entry includes the payor’s name, address, payor ID, and other details.

Insurance Plan Name and Short Name

The plan’s name and short name indicate how the plan will appear on lists and in a patient’s policy record. Practices typically include the expected default copay amount in the plan name, making it easier to select the correct plan when adding a patient’s policy.

Insurance Group

Your practice maintains a custom list of Insurance Groups in the Insurance Groups table. Groups are used for financial reporting and do not affect claims or billing behaviors for procedures.

Address, City, State, Zip and Phone Number

These details for a plan are typically found on the back of an insurance card. They are sometimes used for claim submission and to followup on claims.

Copay Amount

The default expected copay for this plan. You should enter this information in the name of the plan as well, so that selecting the plan will be easy for your staff. A plan’s rules file can override what copay to charge for each procedure.

If a plan charges different copays for different procedures, put the default copay in this field.

Copay questions

A series of Yes/No questions that determine default copay behavior for this insurance plan.

  • Copay Office POS: Is a copay typically expected for a visit to the office?

  • Copay Hospital POS: Is a copay typically expected for a hospital visit?

  • Copay Hospital POS: Is a copay charged for each charged procedure?

Use these questions to define default copay expectations. When handling an encounter’s charges, your PCC system checks these questions and then refers to the rules file, which can override these question and define more precise copay expectations.

Claim Batch

The set of configuration rules that will be used to generate a claim. When charges are posted for an encounter and a claim is queued up, it is labeled as being part of a particular “batch” and will be processed in a specific way to meet the requirements of a payor. Plans are assigned a batch so claims will be submitted in adherence with those requirements.

A plan’s batch for claims is not connected to the plan’s insurance group, which is used for reporting, but the values may match or be similar. For example, your practice may have a reporting group for Medicaid plans as well as a special batch for handling the configuration of medicaid claims.

All Insurance Plans Need a Batch: This field normally shouldn’t be empty. It controls the formatting of your claims for the payer. If you believe you need to add a new batch, contact PCC.

Rules File

A configuration file that can be used to implement special per-procedure behaviors, overriding the default needs for the insurance plan.

When you post charges, PCC checks the rules in this file, also known as the “Special Information File”. The rules set whether procedures should pend the insurance plan at all, appear on claims, capitate, use a special price schedule (rare, as insurance contracts generally disallow this), or write off an amount or percentage of the procedure’s price. Additionally, the rules can define what copay should be charged for each procedure, overriding the Copay Amount for the plan.

If you believe you need to create a new set of rules to meet the unusual billing requirements of a payer, contact PCC. For most situations, select the “standard” rules.

Accept Assignment

A Yes/No question that turns default pending behavior for this plan on and off and controls a corresponding value found on paper and electronic claims.

If this value is set to no, charges posted to this plan will (by default) remain the personal responsibility of the billing account for the patient. The rules file can override this behavior and determine precisely which procedures will pend to the plan.

On claims, this value communicates to the payor whether or not payment should be directed to the practice or the patient. If set to no, the payment should be directed to the patient. If set to yes, the provider has a participation agreement with the payer and the payment should be directed to the practice. Your practice’s insurance configuration for this plan’s batch can override how this value appears on claims.

Medicaid Plan

A Yes/No question that determines whether this plan will follow certain medicaid behaviors by default. If set to “Yes,” then:

  • The plan will always be sorted below non-Medicaid insurance policies when a patient has multiple policy coverage. (If a patient has more than one insurance policy, Medicaid policies will be secondary or tertiary, etc.) If this plan ever needs to be the primary plan in front of a private insurance, you should not set the Medicaid question to “Yes”.
  • The policy will be marked with an “M” for easy reference. For example, nurses may need to grab immunizations from a different location for patients with a Medicaid-type plan. Wherever insurance policies are listed, an “M” icon will appear making it easy for them to identify that the patient has Medicaid.
  • Some reports, such as those found in your Practice Vitals Dashboard, will consider the plan, and any other plans in the same insurance group, to be Medicaid-type plans for reporting purposes.

Capitated Plan

A Yes/No question that sets the default capitation behavior for this plan. If set to yes, then charges posted to this plan will be adjusted off at the time of service. However, the Rules File can override this question and configure the specific desired adjustment behavior for procedures. PCC Support will help set up and configure adjustment behaviors for capitation plans.

Allowable Schedule

The contract fee schedule used for this payer. If your practice enters your contract fee schedules into PCC, you can automatically review claim responses that fail to meet the schedule and report on overpayments and underpayments over time. For more information, see Use Contract Fee Schedules (Allowables) to Monitor Reimbursement.

Payor ID

The identification number used for electronic claim submissions to this plan. Insurance plans from the same company generally share the same number.

Where Do I Find an Insurance Plan's Payer ID or Payor ID?: If you cloned an existing insurance plan of the same company, the ID number may already be correct. Otherwise, the payor’s ID should appear on the insurance card, or you can call the number on the card. The carrier is required to provide an ID number for claim submission.

Eligibility ID

An identification number or alpha-numeric code used for requesting eligibility information for a patient. These are standardized for a given payor, so are usually easy to find on the internet. If you are unable to find an eligibility identification number, contact the payor.

Auxiliary Payor ID

An identifier used for specific situations, such as a secondary medicaid claim submission in which the primary payor required a proprietary identifier (a “Carrier Code”).

Claim Filing Indicator

A parent category for the type of claim submission used for the plan. Most commercial plans are “Commercial Insurance Co.” or “CI”. Medicaid and BCBS have unique claim filing indicators.

Notes

A field for your practice’s notes about the plan. This text is unique per-plan table entry, so to be effective you may wish to copy the note into all copay versions of a plan. The text will appear in the Policies component in PCC EHR.

Insurance Groups and the Insurance Groups Table

The Insurance Groups table is also located in the Tables tool.


This table defines your practice’s customizable payor groups used for reporting.

Insurance groups have a name, a short name, a reporting position, and an “Include in Totals” option which indicates whether or not charges and payments for policies in the group should be included in certain report totals.

All insurance plans in the Insurance Plans table have an assigned insurance group.

If you wish to break out reporting for a subset of an insurance group, you can clone an existing group and enter a new name. Then you can assign the new group to corresponding insurance plans.

Add and Configure a New Clinician in your PCC System

August 3, 2015/in Configure Providers Configure PCC EHR, Configure Billing Functions /by Douglas Beagley

When you add a new clinician to your practice, use the procedures below to ensure that all PCC functions will work correctly.

Let PCC Know: Parts of this process require PCC Support to make changes to your system. Let us know that you’re planning to add a new clinician so we can make the necessary accommodations. Contact PCC Support at 1-800-722-7708 or support@pcc.com.

Enroll the Clinician with Insurance Payers

Contact your payers and enroll your new clinician. This is sometimes called “credentialing” a provider with the payer, or taking steps so that they are “participating” with the payer.

You will not be able to submit claims until the new clinician is enrolled.

Provide Training Materials

It’s never too early to start training your new clinician. Use PCC’s full New User Training for Clinicians outline, or customize it to suit your needs.

Add a New User Account

Add the individual to your PCC system in User Administration. Use PCC’s Add a New PCC User Account to create a user account.

When re-enabling a user, make sure their EHR and Practice Management usernames are the same.

Adding a Non-Clinical User?: Create the user account and select an appropriate role using the instructions outlined here: Add a New PCC User Account.

Add a Provider Group

Provider groups are used for reporting purposes. In most situations, you should create a new group for each new clinician.

Your office may have special reporting considerations for nurse practitioners, medical assistants, and other clinicians. You can set up individual groups, or a single, “Nurse” group depending on your needs.

Use the Tables tool in PCC EHR to edit your practice’s Provider Groups table.

For help with the Tables tool, see Edit Your Practice’s Configuration Tables.

Add the New Clinician to the Provider Table

After you’ve created a new provider group, you can add the new clinician to your tables and assign them to the group. Follow the procedure below to learn how.

Open the Providers Table in the Tables Tool

Open the Tables tool from the Configuration menu and select the Providers table.


Review Provider Information

For each clinician at your practice, you can see their name, Provider Group, their linked PCC EHR user ID, and the three key billing identifiers: Tax ID, NPI, and Taxonomy Code.

Clone or Add to Create a New Provider Entry

Select an existing clinician and click “Clone” or click “Add” to create a new entry.

Enter Clinician Information

In the top section, you can enter the provider’s display names, initials, associated PCC EHR user, and reporting Provider Group.

In the Billing and Credentials section, configure how the clinician should appear on claims. The key identifiers used to process claims are the clinician’s name (first, middle, last), their taxonomy code, their NPI, and your practice’s Tax ID. For information about these fields, see Providers Table Field Reference.

Save Your Changes

When you are finished entering clinician details, click “Save”.

Optional: Configure Custom (Per Insurance Company) Identifiers

In rare cases, an insurance company may require a unique identifier beyond the NPI, Tax ID, or Taxonomy Code for the clinician or the practice. Contact PCC Support for help with special payor configuration needs.

Add NPI Numbers and Other Identifiers to the PCC EHR User Account

The NPI numbers and other details in the Providers table are used on claims to indicate your clinician’s credentials. Clinical and prescribing activity in PCC EHR is also recorded with an NPI number.

Use the User Administration tool to review the PCC EHR user accounts for your clinicians. Add NPIs and other identifiers that affect prescribing and reporting on clinical services.

Log Out and Log Back In

Log out of PCC EHR and close the login window. Log back in to sync your provider’s new information.

Create Claim Holds

If a clinician is not yet credentialed with payers, you can create claim holds to prevent certain claims from being submitted. A claim hold prevents claims from going out for specific dates of service, billing providers, places of service, and insurance plans.

Read Hold Claims to learn more.

Configure the Clinician’s Prescribing Role

Define the clinician’s PCC eRx prescribing role and permissions in the User Administration tool. To learn how, read Set Up PCC eRx User Access.

If the clinician will be prescribing controlled substances, review EPCS: How to Enroll Prescribers and Prescribe. The clinician’s NPI and DEA must be present in User Administration to order a fob.

Contact PCC Support

If you have not done so already, now is a good time to let PCC know that your practice is adding a clinician. Contact PCC Support (802-846-8177 or 800-722-7708, support@pcc.com) so that we can update your notification messages, assist with special claim configurations, adjust provider scheduling groups, and facilitate eRx EPCS setup.

Configure Your New Clinician’s Schedule

Allow Scheduling in User Administration

Indicate that your new clinician can be scheduled for appointments.

Configure Visit Reason Lengths

Enter default visit reason lengths for the new clinician in the Visit Reason configuration tool.

Create a Scheduling Template

Create at least one Scheduling Template for the new clinician in the Provider Hours tool.

Assign a Scheduling Template

Assign your new clinician’s scheduling template in the Provider Hours tool.

Log Out and Back In

Log all the way out, then reopen PCC EHR to pick up the new information.

To learn more about how to configure these features, visit Appointment Book Configuration.

New Clinician Not Displaying on the Schedule?: To troubleshoot, check the following: 1. Is the provider present in the Providers table, with their EHR User populated? 2. Is the Scheduling Provider checkbox in User Administration checked? 3. Does the provider have hours in their schedule template? 4. Have you logged all the way out and back in, closing and reopening the login window? Contact PCC Support for assistance.

Customize Chart Note Protocols

Use PCC EHR’s Protocol Configuration tool to assign existing protocols, and/or duplicate and customize protocols for different visit reasons.

Visit Configure Chart Notes and PCC EHR Components to learn more.

Set Up Auto-Notes and Snap Text

Clinicians can create their own entires for frequently-typed notes.

Read Insert Standard Text in a Chart Note Field, and Expand Short Text into Common Phrases to find out more.

Set a pocketPCC Security Question

Your new clinician can use the My Account tool to review and adjust their pocketPCC security question. They will need your practice’s pocketPCC login URL to access pocketPCC.

For more information, read Get Started in pocketPCC

Optional: Add the Clinician to Chat Groups

Use the Chat Groups tab in User Administration to add your new clinician to relevant existing chat groups, or create new groups. To find out more, read Chat with Groups of Users

Optional: Set a Portal Display Name

In the new clinician’s User Administration entry, select the name that will display in the portal for your new clinician.

Optional: Sign in to PCC Email

Clinicians can access their PCC-provided email service using the steps in this article: Read Your PCC Email with Roundcube.

Optional: Authorize Work from Home Access

Practices can give remote access to clinicians with the User Administration tool. For more information, read Authorize Users for PCC SecureConnect.

Optional: Upload a Signature

Clinicians who want an electronic signature on file can upload their signature image in the Forms tool. Signatures should be written using a black pen on white unlined paper and scanned at a high resolution. Learn more here: Configure Provider Signatures for Patient Forms.

Optional: Update Notify

If your practice uses Notify to automatically remind patients and families of upcoming appointments, your providers’ names can be included in those messages. To ensure that Notify runs smoothly and correctly identifies your new clinician, contact PCC support in advance of the clinician’s start date to provide the new clinician’s name and a phonetic spelling of the name.

Optional: Sign Up for PCC Community and PCC News

When there are important service updates, PCC reaches out to someone at your practice by calling or e-mailing as well as by posting on PCC Community.

Your new clinician can sign up to follow important PCC news announcements and connect with other practices that use PCC’s software and services through the PCC Community site: https://community.pcc.com/

PCC Community is a Great Place to Get Answers: In addition to providing notifications from PCC, PCC Community also includes PCC Talk, an online forum where pediatric practices ask questions and help one another with issues facing their practice. For more information, watch the Get Started with PCC Community and PCC Talk video.

Optional: Create a Login for the PCC Support Portal

Your clinician can ask questions and review their tickets at https://support.pcc.com

Configure Clinician Billing Identifiers: Tax ID, NPI, and Taxonomy Codes

August 3, 2015/in Configure Providers Configure Billing Functions /by Douglas Beagley

On every claim, insurance carriers requires the same clinician information: a name, a tax ID, a National Provider Identifier (NPI), and a taxonomy specialty code. Use your practice’s Providers table to add or update these identifiers for your clinicians.

Where Do You Get Your NPIs?: Before updating your clinician billing identifiers, you may need to obtain an NPI for both your clinicians and your practice. You can register for an NPI online at the NPPES Web site (https://nppes.cms.hhs.gov/).

Update Clinician Billing Identifiers

When you add a new clinician to your practice, or you need to adjust billing identifiers for a clinician when they become credentialed, use the Providers table in the Tables tool and then update the PCC EHR user information.

Open the Providers Table in the Tables Tool

Open the Tables tool from the Configuration menu and select the Providers table.


Review Provider Information

For each clinician at your practice, you can see their name, Provider Group, their linked PCC EHR user ID, and the three key billing identifiers: Tax ID, NPI, and Taxonomy Code.

Edit a Provider Entry

Double-click on a provider to review their details.

Adding a New Clinician?: You can also use "Clone" or "Add" to create a new entry. To learn more about working in the Tables tool, see Edit Your Practice's Configuration Tables.

Adjust Clinician Information

In the top section, you can adjust the provider's display names, initials, associated PCC EHR user, and reporting Provider Group.

In the Billing and Credentials section, configure how the clinician should appear on claims. The key identifiers used to process claims are the clinician's name (first, middle, last), their taxonomy code, their NPI, and your practice's Tax ID.

Save Your Changes

When you are finished updating clinician details, click "Save".

Review Your Practice or "Office" Provider

By default, the "Office" provider in your Providers table is used as the "Provider of Billing" on an insurance claim. You should double-check that it is accurate, and contains your practice's ten-digit Type 2 NPI and nine-digit Tax ID.


Optional: Configure Custom (Per Insurance Company) Identifiers

In rare cases, an insurance company may require a unique identifier beyond the NPI, Tax ID, or Taxonomy Code for the clinician or the practice. Contact PCC Support for help with special payor configuration needs.

Add NPI Numbers and Other Identifiers to PCC EHR User Accounts

The NPI numbers and other details in the Providers table are used on claims to indicate your clinician's credentials. Clinical and prescribing activity in PCC EHR is also recorded with an NPI number.

Use the User Administration tool to review the PCC EHR user accounts for your clinicians. Add NPIs and other identifiers that affect prescribing and reporting on clinical services.

Providers Table Field Reference

  • Provider Name, Short Name, and Initials: PCC reports and software interfaces use these fields to indicate a specific clinician. The contents of these fields do not appear on claims.

  • EHR User: Providers in the Providers table are associated with PCC EHR users. This association links the provider to scheduling, charge posting, prescribing, and other PCC EHR functionality.

  • Provider Group: PCC’s various reporting tools can group providers by provider groups, which are defined in the Provider Groups table. By default, PCC software is configured so that each clinician has their own group.

  • First, Middle, and Last Name: The First, Middle, and Last name fields are used as required on insurance claims. They should match the clinician’s legal name under which their NPI is registered.

  • Provider Type: The Provider Type field controls certain billing behaviors in PCC EHR’s software. If it is set to Real, the provider is a normal clinician (M.D., nurse, or similar) that can appear on the claim as the rendering provider. When you no longer generate claims for a provider, you can change the value to “Retired” and they will no longer be an option when posting charges. If a provider is marked with a type of “Not Real”, then the Billing Provider field in Post Charges will be blank by default, and PCC EHR will prompt the user to select a provider for the claim.

  • Taxonomy Code: A taxonomy code indicates a provider’s speciality. You can start typing to pick from a list of taxonomy codes. 208000000X is the most common taxonomy code used for pediatricians.

  • NPI: A provider’s National Provider Identification number appears on outgoing insurance claims. Clinicians can register for an NPI online at the NPPES Web site (https://nppes.cms.hhs.gov/).

  • Tax ID: A Tax ID appears on outgoing insurance claims. Generally, this will be your practice’s business Tax ID, and will be the same for each clinician at your practice.

  • License Number: In rare circumstances, a billing provider’s license number can appear on an outgoing insurance claim.

SRS Financial Report Reference

August 3, 2015/in Previous System Tools /by Douglas Beagley

The Smart Report Suite (srs), found in PCC’s former software suite (Partner), contains a number of useful reports for financial analysis. Read below to learn about some of the default reports. You can also create your own reports in SRS, and export SRS reports for use in a spreadsheet.

srs: Billing Report by Family

The Billing Report by Family, located in the Billing and Collection section of the Smart Report Suite (srs), will help you find personal or insurance bills that have been billed multiple times. You can use the report to create a list of all personal charges that have been billed over 10 times, for example, or find all insurance charges for which you have resubmitted a claim more than twice. The report could also show you a list of all charges that have never been billed. Use this report to make sure charges are not slipping through your fingers.

srs: Billing Report by Responsible Party

The Billing Report by Responsible Party, located in the Billing and Collection section of the Smart Report Suite (srs), will help your billing staff deal with outstanding insurance accounts. Use the report to quickly and easily find all insurance claims that were submitted more than 30 days ago, or any length of time you specify. With this report, you can keep an eye on unpaid charges that are approaching timely filing limits.

srs: Billing and Collection Reports

The Smart Report Suite (srs) contains a number of reports that are useful for your daily billing needs. The Billing and Collection section, for example, has reports for generating a family billing history, a billing error report, and various aging tools to track outstanding charges. Remember that PCC also offers tools for customizing any existing SRS report or writing a new report from scratch. Contact PCC Software Support for more information.

srs: Payment Detail By Check Number (in Posting Order)

A payment’s check number is a convenient reference when untangling an end-of-day balance problem. The Payments Detail By Check Number, along with other payment reports in the Payments and Proving Out section of the Smart Report Suite (srs), provides a list of check numbers along with relevant visit information.

srs: Payment and Proving Out Reports

This section of srs includes customizable versions of daysheet and deposit. PCC can help you change these reports or use srsgen to create an end-of-day report tailored to the needs of your office.

srs: Per Visit Analysis

The Per Visit Analysis report details how much work your office is doing for each visit category and coding level.

srs: Per Visit Analysis By Payor

The Per Visit Analysis By Payor (activity style) report will show you your total and per-visit revenue, broken down by payor. Here is an example:

Use this report to compare payors and review your activity for a given date range.

srs: Other Financial and Practice Management Reports

The Smart Report Suite has dozens of excellent reports for the practice manager, including a Billing and Collection Reports Section, a Trend Analysis section, and sections with reports analyzing charges and visits. Remember that every srs report can be customized to the specific needs of your practice. Contact PCC Software Support for help at 802-846-8177 or 800-722-7708.

srs: Aging by Responsible Party and Provider

This report shows what percentage of your business is tied up in each of your insurance groups and includes aging categories.

The Aging categories at the top of the report indicate the days since the time of service. Use this report to evaluate your weaknesses in accounts receivable and see how long different carriers take to pay. The practice in the image above has an excellent insurance accounts receivable, with few claims outstanding beyond 60 days. Their private-pay collections may need improvement, however.

srs: E&M Coding Distribution (Practice Total)

Does your practice charge a typical sick visit coding distribution? This report totals all of the sick visits performed for a specified date range and displays the totals for each visit category. Use this report to review your sick visit coding over a period of time. For the practice in the report below, 99213 visits account for about 68% of all sick visits.

srs: E&M Coding Distribution by Provider

This report compares sick visit coding frequency and subtotals by provider. Run this report to examine the sick-visit coding behavior of each of your providers.

srs: Gross Collection Ratio Report

The Gross Collection Ratio shows total charges and collections for each insurance groups, grouped by year. The report shows percentages so that you can see what percentage of each insurance group’s charges end up as deposits.

Use this report as a quick comparison of how well different insurance companies reimburse.

srs: Total Active Patients (by Sex and Age Group)

The Total Active Patients (by Sex and Age Group) report in srs shows a summary of age and sex distribution at your practice.

If you are a pediatric practice, you can monitor your age distribution to make sure your patient base is weighted towards younger patients. This report is also a convenient way to track practice population. To see this report, run srs, select Patient Demographic and Policy Reports, and then select Total Active Patients (by Sex and Age Group).

srs: Payor Mix Analysis

How much of your practice’s income depends on a single payor? Do some insurance groups constitute a large percentage of your work done but a smaller percentage of your actual income?

The Payor Mix Analysis report shows charge and payment percentages, along with units, RVUs, and Deposits. This report can help you understand how important each payor is to your practice.

srs: Per Visit Analysis by Payor

This report analyzes your charge data by visit category. For example, it can compare different levels of Well and Sick visits. The visit types are sorted by insurance group. The report includes total procedures performed for each visit type.

Use this report to evaluate in more detail if the work done for each insurance group correlates to the amount deposited.

srs: Per Visit Analysis By Provider

The Per Visit Analysis By Provider shows how many of each visit type your providers performed. Use this data to plot the coding curve of each of your providers as well as to review the workload of each provider for any date range.

srs: Pricing Analysis (RVU Report per Procedure)

The Pricing Analysis (RVU Report per Procedure) report shows your Practice’s average price for each procedure you performed during a specified date range and compares it to the standard Medicaid reimbursement for your region. Because the report shows total procedures performed for a given date range and can calculate expected reimbursement based on a percentage of Medicare’s reimbursement, you will be able to spot procedures for which you may be undercharging.

You can use this report to calculate new prices based on a percentage of Medicare’s reimbursement and review the possible effects of the price change.

srs: Total RVUs By Provider

The Total RVUs By Provider Report summarizes the work done by each provider in your practice. Rather than measuring work by the number of visits, this report compares the number of RVU units performed and amount charged by each provider.

Use this report to analyze provider performance and reveal patterns of under or over-coding.

srs: Sick/Well Visit Analysis (Practice Average)

The Sick/Well Visit Analysis displays the number of sick and well visits performed at your practice for a specified date range. Total amounts charged and deposited are also displayed, illustrating how each visit type contributes to your practice’s total revenue.

srs: Sick/Well Visit Analysis by Provider

This report compares visit-type data among your providers.

Use this report to see the total number of sick and well visits each provider saw within a specified date range.

Chart with Answer Memory, Last Answer, and Your Custom Auto-Notes

August 3, 2015/in Chart a Visit Chart a Visit /by Douglas Beagley

PCC EHR has several unique tools that help you enter notes on a chart faster. This help article lists those features and includes procedures and links for configuring them.

  • Historic Answer Memory: PCC EHR remembers the answers that you type into a chart note and then supplies a list of previous common answers. This is sometimes called “Historic Answers”. You can configure whether fields should filter remembered answers by patient or by provider.

  • Last Answer: PCC EHR can display the last saved answer for certain types of questions. You can turn the feature on and off for fields. When you chart, you can click “Last Answer” to enter the text into a chart note. This is typically used to view and record the patient or family’s last answer to a question.

  • Auto-Notes: PCC EHR can store and pop into place your custom notes for recurring field on a chart note, like Review of Systems. You can configure which protocols and which items will have an auto-note, and you can assign a unique auto-note to any selection (Normal, Abnormal, etc.) for all providers at your practice or per-provider.

Watch a Video: Watch Answer Memory, Last Answer, and Auto-Notes to learn more.

Historic Answer Memory

PCC EHR’s Historic Answers, also called “Answer Memory”, tracks previous answers for many fields on your chart notes. If you have a typical way of answering certain questions, or if you want to select from recent responses, the pull-down answer memory will help you chart faster.

In addition to the pull-down menu, PCC EHR often display matching answers as you begin typing.

Display Patient or Provider's Answers?: For most questions, you will want to choose from your past notes as a provider. You have a certain way of recording a diagnosis or description. In some cases, it makes more sense to filter the list to include the patient’s common responses instead. You can set this filter in PCC EHR’s Protocol Builder.


Patient’s Last Saved Answer

The Last Answer feature displays the patient’s most recent saved response. It also provides a single-click button to enter the last answer in today’s chart note.

You can turn on or off the Show Last Answer feature for different components in your chart notes. Edit the component in PCC EHR’s Component Builder.

Last Answer is available for any Generic Check, Q & A, or Generic Text style component.

Last Answer is also found in pocketPCC.

Auto-Notes

PCC EHR’s Auto-Notes feature can enter your default notes at the click of a button while you chart.

When you click on a radio button selection while charting, or the “Make All” option at the top of the component, PCC EHR can auto-fill the notes field with your standard note.


For example, you may have a standard note for what “Normal” means for a physical exam. After you setup Auto-Notes, clicking on “Normal” or “Make All Normal” will add your notes to the chart note automatically. You can then review and confirm or revise the note text, as needed.

Each provider, or your whole practice, can implement standard notes for each choice (i.e. NL, ABN, N/E) for each radio-button style component, for each visit protocol. Read the sections below to learn more.

The same options are available within pocketPCC.

You can learn more about how to use, create, and edit PCC EHR Auto-Notes by reading the Auto-Notes help article.

Export SRS Results to a Spreadsheet

August 3, 2015/in Review Billing and Practice Management Reports Previous System Tools /by Douglas Beagley

You or your practice’s accountant may use financial data from reports to analyze profits and make policy decisions for the future of your practice. srs can produce thousands of different reports, and you may wish to export those reports to another program, such as a spreadsheet, in order to make graphs or combine the numbers with other information.

Watch a Video: You can learn the steps in this article by watching the SRS Reports video.

Transfer an SRS Report to Your Computer

You can use e-mail to send yourself a “Comma Separated” e-mail attachment containing srs data. You can then save the e-mail to a file on your computer and open it in a spreadsheet program.

Select and Run the srs Report

Run srs, choose the category and report you need, and enter the desired date range. You can retrieve or add criteria to limit the output, if desired.

Select “E-mail”, Enter an Address, and Select “Spreadsheet (Excel)”

On the Report Output Selection screen, choose “E-mail” as the destination and “Spreadsheet (Excel)” as the output format. If the default e-mail address is not correct, enter a different address. Press F1 – Generate Report to continue.

Check Your E-Mail

After a few minutes, the report should appear in your e-mail inbox.

Save the E-Mail to a File

Click on the “File” menu and select “Save As…”

Pick a Save Location

Use the standard Windows save dialog to save your report in an appropriate location. If a “File Type” or “Save as type” option is visible, change it to “Text File” as shown.

Load an SRS File into a Spreadsheet Program

Follow the procedure below to load a saved report output into a spreadsheet application, such as Excel or OpenOffice.

Launch Your Spreadsheet Program

First, run your spreadsheet program. There are many different spreadsheet programs. The most common one is Microsoft Excel™. Another popular program that is compatible with Microsoft Excel is Calc, which is part of OpenOffice.org’s office program suite. PCC recommends OpenOffice to its clients and can provide some assistance with installing and using it.

Click on the “File” Menu and Select “Open…”

From within your spreadsheet program, choose the Open option from the File menu:

Find Your srs File

If you saved the report from an e-mail message, look in your My Documents folder, or wherever you saved the message.



Select Your File and Click “Open”

PCC’s srs program gives the file a name that is based on the date you ran the report. Click on a file to select it and then click “Open.”

Confirm Data Formatting Details

Some spreadsheet programs, including OpenOffice’s Calc, will show you a brief summary of how the data will be imported. There may be options on the screen allowing you to import the data in a different way.

The default settings should work fine, but you should double-check that “Comma” or “Comma Separated” is selected.

View Your Data, Make Adjustments

Your spreadsheet program should load the data from the file into a new spreadsheet.

You may wish to make adjustments to the column widths if the contents of the fields do not fit perfectly. Once your data is in a spreadsheet, you can manipulate it using the various calculation features of the spreadsheet, generate graphs and charts, and create attractive, printable reports for presentations.

If you want to learn more about using a spreadsheet program, there are many books and online resources available. For help with OpenOffice, visit OpenOffice.org or contact PCC for installation assistance.

Run Reports in the Practice Management Window (Partner)

August 3, 2015/in Review Billing and Practice Management Reports Previous System Tools /by Douglas Beagley

PCC EHR’s Report Library includes reports for front desk, administrative, clinical, patient recall, and more. PCC’s previous software suite, Partner, included some specialized, customizable reports for billing and financial analysis. In the sections below, you can learn how to run these under-the-hood reports found in the Practice Management window.

If you need help finding a report, call PCC support at 802-846-8177 or 800-722-7708. PCC creates custom reports for practices every day, and we can also teach you how to create your own.

Start in Practice Vitals Dashboard: Every PCC office has a Practice Vitals Dashboard. It’s a great place to get started with reporting! Visit Practice Vitals Dashboard to learn more.

Overview: Run a Report in the Practice Management Tool

Read the procedure below to learn the basics of running reports in the Practice Management window.

Run a Report Program

First, find and run a report in the Practice Management window. Many reports are available inside the Smart Report Suite (srs) program.

Select Report Options

The first screen of all report programs contains options. Here are two examples of report options screens:


The date range is the most frequently used report option. Some reports have subtotaling, filtering, and sorting options that dramatically change the appearance or content of the final report.

Smart Report Suite Options: The srs-style reports display a Date Range selection screen followed by a Restriction Criteria screen. For more information, read The Smart Report Suite.

Press F1 Generate Report

Other Report Options: The F1 key generates most Practice Management window reports. Some programs include multiple reports available from different function keys, such as the Patient Information (patinfo) and Insurance Reimbursement Analysis (ira) report programs.

Optional: Select Details for Report Criteria

After you press F1 to generate a report, the report program may ask you filtering questions for the report criteria or other options that you selected. Some options require additional details.

For example, if you answer “No” to the “All Providers?” option in the Appointment Summarizer (appts) report, then the program will ask you to select providers to include. The selection screen has useful function keys to speed up selection.

Select Report Output Destination

You can read Practice Management reports on your screen, format them for spreadsheets, or print them in an attractive, full-color PDF. While running a report, you will select output options in one of two different ways: on the main options screen, or on a Destination Selection screen after you press F1:

Or:

Mark your selection with an X and press F1 to continue.

Additional Options: After you mark your Destination Selection, you may see additional options. If you select to “Print” the report, for example, you can then choose a specific printer and/or a printing style.

View Completed Report

Unless you choose to send the report directly to a printer, an e-mail address, or another location, your report will appear on the screen:

Navigating the Report: Use the arrow keys, the Page Up and Page Down keys, and the F2 – Jump to Top and F3 – Jump to Bottom function keys to navigate around the report. In some reports, the function keys may not be available.

Searching the Report: Press F8 – Search Pattern, enter search text, and then press Enter to search.

While searching, you can press F7 – Search For Next to view the next matching result or press F8 – Search Pattern to clear the search or enter a new search pattern. The “Search on whole words” option allows you to specify whether your search should only find results that are separate words and not part of a larger word.

If you are viewing a report without function keys, you can search for text by pressing the slash key (/), typing a search word, and pressing Enter. You can then jump down to the next search result by pressing N for “next result.”

Optional: Send Report to a New Output Destination

After reviewing a report on the screen, you may decide to print or send the report to a new destination. If your report includes function keys, press F4 – Send To.... The Destination Selection screen will open and allow you to make another selection.



Select Report Criteria in Practice Management Reports

Most Practice Management (Partner) report programs begin with a screen of options that will define and restrict the report’s output. The default settings on the options screen may give you exactly the report you want. If not, you can make changes that will limit the report’s results or format the output.

Here is the options screen for the Insurance Reimbursement Analysis (ira) report:

After you set and select your desired options, press a function key (usually F1), to read the report. Sometimes there are several function keys which run different reports. The ira report, for example, contains three different report formats, labeled F1 through F3, as shown above.

The next sections contain explanations of each of the different types of options you may find in Practice Management (Partner) reports.

Dates

Almost every report can be restricted by a date range. The default date range for ira is year-to-date, the default date range for Deposit Slip (deposit) is today’s date. You can alter the date range by entering new dates in the From and To fields.

Reports that show the age of balances, such as the Insurance Accounts Receivable Summary ([prog]insaging[/prog]) and the Personal Money Tracking Assistant ([prog]persview[/prog]), allow you to measure the age by three different dates:

  • Transaction Date: Age the balance by the date of service, when the visit occurred.

  • Posting Date: Age the balance by the date the service was entered into your PCC system.

  • Payor Date: Age the balance by the date on which the charge became the responsibility of the current party. This is also called the “Payor Responsibility Date.”

In most situations, aging by transaction date makes the most sense. You usually want to know how old charges really are, from the date of service. Many reports offer only that option.

When Do You Use the Payor Date Option?: If you are reviewing overdue personal accounts, for example, you would want to use the Payor Date when you review accounts in (or create overdue letters) in persview. Otherwise, an old charge that was just rejected by the insurance company last week would trigger a late notice for the family! When you choose the Payor Date option, however, your PCC system is smart enough to know that the charge has only been the family’s responsibility for a week.

Sort and Subtotal Features

The “Subtotal Data By” fields, available on some options screens, have a profound effect on a report’s output. Different subtotal lines reshape a report and can make it more useful for your practice management decisions. Enter an asterisk (*) in any subtotal field to see the different variables by which you can subtotal the report.

If you want to know how many times each provider performed each procedure over a period of time, run ira and enter “Provider of Service” followed by “Procedure” in the Subtotal Data fields. Then press F1 – Summary Report.



The resulting output will include a section for each provider, details about their procedures for the given date range, and useful totals.

If you reverse the order of the items in the Subtotal Data By fields, and run the same report, ira will sort and total the same data in a different way:



The providers’ numbers for each procedure are identical in the two examples above. The different subtotal field order, however, provides an alternate way to analyze the data.

The Deposit Slips (deposit) program also has a sort/subtotal feature. If your practice needs to balance its cash drawer by user, for example, you could set the options as follows:



The deposit options screen displays the subtotal features differently from the ira screen, but the feature works the same way.

Some reports, such as deposit, include a “Totals Only” option. This option removes the individual lines of the report, leaving only the totals:


Use “Totals Only” to simplify the report output and view only the total and subtotal information.

Destination Selection

Destination selection options often appear on the criteria screens of reports. For more information, read the Destination Selection section below.

Advanced Criteria Option Screens in Practice Management (Partner) Reports

Many Practice Management reports have options on the initial screen that will cause other configuration screens to appear before the report output is generated. With these options, you can include or exclude large amounts of report data and make a report more useful. The main option screen asks a criteria question, and the subsequent screens ask the user to fine-tune that criteria.

For example, the ira option screen includes a series of yes/no questions:

The Patient Recaller (recaller) option screen contains a long pick-list of possible criteria:

If you answer “No” to any of ira‘s questions, or select a criteria item in recaller, the report will need to ask you which of the selected items you want it to include.

In the examples shown above, the user wishes to run each report for only a single insurance company. They changed the “All insurance?” question to “No” in ira, they checked off “Include Insurance Plan(s)” in recaller. When they run either report, your PCC system will ask them which insurance companies should be included:

You can scroll through the list with the arrow keys or by pressing Page Down and Page Up. Press F2 – Select to mark an item you wish to include. Press F1 – Process to continue.

The image above shows insurance company selection, but the screen is identical for procedures, diagnoses, providers, or any other restriction criteria. You will see one such screen for every criteria option you selected on the report’s main options screen.

Here is a full explanation of each of the screen’s function keys and how to use them to select entries:

Function Keys on Advanced Criteria Screens

F1 – Process

Press F1 to run the report using all of the items you have selected. If you do not first select an item, the final report may be blank.

F2 – Select

Press F2 to select the currently highlighted item. You can select more than one entry. Selected entries will be marked with an asterisk (*). If you select a “GROUP” item, all of the items within that group will be included. Press F2 a second time to deselect an entry.

F3 – Select All

Press F3 to select all entries. If you want your report to show results for all insurance companies except for a few, you could press F3 and then deselect the entry or entries you do not want to include.

F4 – Select None

Press F4 to deselect all the selections you have made and start over.

F5 – List By Group

Press F5 to condense the list of options. The individual items will disappear and you will see only the groups.

Insurance companies, providers, and procedures all have groups. Selecting the BCBS Group is much easier than selecting every BCBS plan individually. You can modify your groups in the Tables tool, found in the Configuration menu in PCC EHR.

F6 – List By Pattern

Press F6 to search for an item. You can search by name or any number that appears in an item’s title. The search screen gives detailed instructions:

After entering a search item and pressing F1 – Process Pattern, you will see a list of all items that contain the pattern you entered:

After you select desired items from the search results, press F1 – Process. The report will return you to the complete list, allowing you to make additional selections.

After you make your selections, press F1 – Process to continue. If you answered “No” to several questions or selected more than one criteria on the report’s main options page, the report will display a separate selection list for each one.

Select a Destination for a Practice Management Report

Reports can be viewed on your computer screen or sent to a printer. Some reports can also be e-mailed.

The destination options for a report either appear in a section of the main options screen:

Or, they will appear on a Destination Selection screen after the main options screen:

Use the arrow keys to select the output destination you need.

While viewing some reports on the screen, you can press F4 – Send To... to bring up the Destination Selection screen and pick a new destination.

Destination Options

  • Screen/View on Screen: Show the report results on the screen only. Some reports will then ask if you wish to print before leaving the screen.

  • Mailbox/E-mail: E-mail the report to an e-mail account. Some users use the Mailbox option to transfer a report to their PC and then load it into a spreadsheet program. Contact PCC for assistance or read the SRS section below for more information.

  • Print: Send the report output directly to a printer. You can send the report to your default printer or enter a specific printer name. Enter an asterisk (*) in the printer name field to see a list of available printers.

  • File/srsfiles: Send the report output to a file stored on your server. This option is only available in the Smart Report Suite and a few other reports. Read the SRS sections below for more information on how to control criteria and output in srs and retrieve files from the srsfiles program.

  • Save to Workstation: Transfer the report directly to your computer workstation.

Interactive Reports: Some reports can generate an interactive view, allowing you to jump around and perform operations while reviewing the report output. Read the Interactive Reports section for more information.

View Report Output on the Screen in Practice Management

Practice Mangement reports appear on the screen either as plain text or through a standard interface.

Navigate a Report

Use the arrow keys or the Page Up and Page Down keys to move around the report. If function keys are available, you can also press F2 – Jump to Top and F3 – Jump to Bottom.

Search a Report

While viewing any plain text output, press the slash key (/), type a search pattern, and press Enter to search. You can then step down to each search result by pressing the N key.

If you are viewing a report within a Practice Management interface, as shown in the image above, press F8 – Search Pattern, enter a search pattern, and press Enter.

You can then press F7 – Search For Next to step down to each search result.

Choose a New Output Destination

If you are viewing a report within a Practice Management interface, as shown in the image above, press

F4 – Send To...

to return to the Destination Selection screen and pick a new report output.

Use the Smart Report Suite to Create Custom Reports

August 3, 2015/in Review Billing and Practice Management Reports Previous System Tools /by Douglas Beagley

When you need to create a custom report for a front desk, clinical, or administrative need, use the PCC EHR Report Library.

In addition, PCC’s Practice Management window includes PCC’s previous report library tool, the Smart Report Suite (srs).

Read below to learn how to operate srs and run reports, create custom reports based on thousands of different criteria combinations, and export your reports for use in a spreadsheet program.

Video: Watch Run SRS Reports to learn more.

Run an SRS Report

Follow these steps to run any srs report.

Run srs

You can run the Smart Report Suite from the Practice Management window. The location of the program may differ at your practice.

Select a Report Category

For your convenience, srs reports are sorted into several categories. Choose a category and press F1 – Select Category to see a list of reports on the subject you have chosen:

Choose a Report and Press

F1 – Select Report

Use the arrow keys to pick from the list of reports and press F1 to run the report. Press Page Down to see the rest of the list if there are too many report to fit on one screen. Reports are sorted alphabetically by name.

Enter a Date Range

The report will only include data from within the specified date range. After entering “from” and “to” dates, press F1 – Generate Report to continue.

Some reports may ask additional questions about the date range. In the example above, srs needs to know if the dates entered should limit the output based on the date of the transaction (Transaction Date) or based on the date the information was entered into PCC (Posting Date).

Optionally Adjust Report Criteria, and Then Press

F1 – Process

Read the sections below to learn more about criteria options. To use the default settings, simply double-check the dates you entered and press F1 – Accept Criteria.

Choose the Output Destination and Press

F1 – Process

You can send srs output to the screen, a printer, your e-mail inbox, or to a workstation or PCC server account. You can also change the format so it will work in a spreadsheet, such as Microsoft Excel or OpenOffice. Read below to learn more about these output destination options.

Review Results

When the results appear on your screen, you can press Page Down or the space bar to scroll through them. Use the right and left arrow keys if the report extends off the side of the screen.

When you are finished reading the report, press F12 or Q to quit the report. srs will ask you if you want a printed copy, and then return you to the report’s date selection screen.

Work with SRS Report Criteria

You may wish to run an srs report for only one provider, one procedure group (such as “Well Visits”), or a combination of restrictions. srs allows you to restrict by a wide variety of criteria. Once you have configured a set of criteria for a report, you can save and restore that criteria at a later date.

Add a Criteria to an SRS Report

Follow the steps below to learn how to add criteria restrictions to an srs report.

Select and Run the Report

Find and begin running the desired report in srs. Enter a date range for the report.

Press

F8 – Add Criteria

On the “Confirm Criteria” screen, press F8 to add criteria.

Enter or Search For the Criteria Categories

Enter each of the criteria categories you want to use to restrict the report.

You can enter an asterisk (*) to view a list of all available criteria and select the one you want to use as a restriction.

As with other look-up fields, you can also use the asterisk to search for a particular word or phrase. For example, enter “*insurance*” to see a list of restriction items containing “insurance.”

Press F1 – Proceed to Continue

For Each Criteria You Chose, Make a Selection

For every criteria category you selected, srs will show you a screen with a list of possible restrictions. Select each item (or group) you wish to include on your report and press F1 – Process.

As with the restriction lists in other reports, you can use the F5 – List By Group and F6 – List By Pattern functions to make selecting the desired criteria faster.

Review Criteria Selections, Run the Report

When you are finished with each of the restriction list pages, srs will return you to the Review Criteria page. Check your work and press F8 – Add/Edit Criteria again if you need to make changes. Press F1 – Confirm to run the report.

Save and Retrieve SRS Report Criteria Sets

On the Review Criteria page, you will see two options for saving your criteria selections:

F4 – Save As Default

Press F4 to save the current report criteria as your personal default. Whenever you log in and run this report, the criteria you have assigned and the restrictions you selected will be used automatically.

F5 – Save Rpt Criteria

Press F5 to save the current report criteria to a file that can be restored later. You will see a screen asking you to name and describe the criteria you have selected. Be as clear and detailed as possible.

You can save multiple sets of criteria and then retrieve them from the date selection screen whenever you run the report.

When you wish to retrieve a saved criteria file, press F8 – Restore Criteria from the Date selection screen:



Select the criteria set that you wish to retrieve, and press F1 – Restore File to load it into the report.

Share with a Colleague: If you want to share your custom criteria with someone else in your office, save it as a set as described above. Then show your coworker how to retrieve your saved report criteria. They can then press F4 – Save As Default and they will never need to open the criteria file again.

Export SRS Results to a Spreadsheet

You can export any SRS report as a spreadsheet, and then open it in spreadsheet software, such as Microsoft Excel or OpenOffice.

Read Export SRS Results to a Spreadsheet to learn more.

Change the Copay and Responsible Party for Posted Charges

August 3, 2015/in Get Started Edit Charges and Encounter Claim Information Edit Charges and Encounter Claim Information /by Douglas Beagley

How do you change the responsible party for an encounter’s charges, and how do you change the expected copay (or personal amount due) for a charge?

Update the Patient’s Insurance Policies and Expected Copay

Start by fixing the patient’s policy information. Your practice can update a patient’s policies, including their expected copay, at any time before or after charges are posted. Use the Policies component, which is found in Patient Check-In, in the Demographics section of the chart, in the Post Charges tool, and wherever else your practice decides it should be visible.

When you update policy and copay before you post charges for an encounter, they will pend the correct payer and the correct expected copay will be indicated for the visit charge.

Adjust the Copay and Responsible Party as You Post Charges

As you post charges for an encounter, you can adjust the responsible party for each charge and change the copay or “Personal” amount due for each charge.

Read Post Charges to learn more.

Use “Edit Charges” to Change the Copay and Responsible Party

After charges are posted, you can make changes in from the Billing History in the patient’s chart. Select an encounter and click “Edit Charges” to change encounter details, including the code suffix, responsible party, and amount due personal (typically the copay) for each procedure.


After making changes, you can optionally queue up a new claim. Read Edit Encounter Charges and Resubmit Claims to learn more.

Change the Copay and Next Responsible Party in the Insurance Payments Tool

As you post insurance payments and adjustments, you can change the copay amount if (for example) the payer waives the copay or the ERA indicates a different expected amount.



You can also select the next responsible party for any remaining amounts due on the charges.

You can select from any policy on the patient’s record, and if necessary make changes to the patient’s policies on the same screen.

Later, you can use the History tab to edit any insurance payment and make the same changes, adjusting the copay and next responsible party.


Review What Appeared on a Printed Bill

August 3, 2015/in Bill the Family Bill the Family /by Douglas Beagley

How can you review a copy of an account’s bill to verify what was sent to them on their statement? When your PCC system generates account bills, either for printing by a third-party service or in your office, it keeps a copy of the bill’s contents. Use the Bills tool in PCC EHR to review the text on the bill.

Review the Bill in the Bills Log

Follow the procedure below to view a family’s last bill.

Check When the Family Last Received a Bill

In the Demographics section of the patient’s chart, check the date when the account was last sent a bill.

Open the Log Tab of the Bills Tool

First, open the Bills tool and visit the Log tab.


Open a Bill Run

Double-click on an entry to see the details of a bill run.


Double-Click to View a Bill

Select or search for an account and double-click to see the text that appeared on their bill.


Change the Service Provider or Billing Provider After Charges are Posted

August 3, 2015/in Edit Charges and Encounter Claim Information Edit Charges and Encounter Claim Information /by Douglas Beagley

You may need to assign a billing provider to an encounter after it has been posted. Use the Edit Charges in the patient’s Billing History to make changes.

First, select the encounter in the Billing History section of the patient’s chart. Then click “Edit Charges”.

At the top of the screen, you can change the provider of service.

Visit the “Claim Information” section to set a supervising billing provider, who will appear on claims.

When you are finished, click “Save + Post”. For information about queuing up a new claim, making other changes, or resubmitting claims, read Edit Encounter Charges and Claim Information.

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