PocketPractitionerä Manual

Integrated Patient Tracking and Charge Capture

Version 6.0

 

 

Contents

 

1. Getting Started with PocketPractitioner

2. A Quick Tour of PocketPractitioner

·         Patient List

·         Patient Edit

·         PocketPractitioner Diagnosis List

·         PocketPractitioner Medication List

·         PocketPractitioner Procedure List

·         Patient Diagnoses

·         Patient Medications

·         Patient Charges

·         Patient Notes

·         Menu / Find / Applications

3. A Quick Tour of PocketPractitioner Office

·         Opening PocketPractitioner Office

·         Main Menu

·         Print Reports

·         HotSync Options

·         Setup

·         Patients

·         Diagnoses / Medications / Procedures

4. About the Database Structure

·         Overview

·         Changing the Handheld User Name

5. Setup for Multiple Users

6. Security

·         Handheld

·         Desktop

7. Backup and Restore

8. Printing

·         Overview

·         Printing with PocketPractitioner

·         Printing with PocketPractitioner Office

9. Importing

 

1. Getting Started with PocketPractitioner

If you do not read manuals, at least read this

PocketPractitioner was designed for users like you. However, here are a couple of tips to help you along the way.

  • When you are in the Patient List, tap the Palm Menu button to show all items in the PocketPractitioner Menu. Be sure to check out Options -> Preferences to customize your program and set your password. Tapping the Menu button from any other location will bring up the menus appropriate for that form.
  • To return to the Patient List from any location, tap the Done or Back Arrow buttons.
  • For PocketPractitioner Office users, you must open PocketPractitioner Office on the PC to be able to synchronize data during the HotSync. Click on the desktop shortcut or look in your Start Menu. Also, critically important, your initial security Name is "Practitioner" and your initial Password is left blank.
  • We suggest that you keep duplicate paper records until the system is fully installed and tested.
  • If you are printing notes and charges, we suggest that you keep printing current to minimize loss of data in the event that your Handheld is lost or malfunctions for any reason.

For the rest of you, please read on

PocketPractitioner is a complete package to provide integrated Patient Tracking and Charge Capture. All elements of content were chosen with care to provide maximal functionality in the simplest package. Reading through this manual will help you understand the logic involved and will enhance your ability to utilize its many functions.

Functional and Cost Effective

There are no hidden consulting or subscription costs with PocketPractitioner. You receive industry-standard software tools, and you have total control over all data elements on your Handheld and PC. The total cost of ownership is low, and your return on investment for the billing products is probably less than a few weeks.

 

Key Features

  • Patient Tracking. You track patients in any clinical setting, record patient information, create patient notes, and maintain diagnosis and medication lists.
  • Charge Capture. You capture charges at the point of care utilizing current procedure® and ICD-9-CM codes.
  • Printing. Patient charges, notes and patient lists export with ease to a Palm Memo. You may print reports directly from the Handheld to an Infrared or Bluetooth printer using third-party software, such as PalmPrint or PrintBoy.  You may also print reports from the PC to a standard printer using using Microsoft Outlook or Outlook Express, the Palm Desktop, or the PocketPractitioner Desktop.  With the Office version, you will have multiple advanced reporting options in the PocketPractitioner Desktop application.
  • Intuitive user interface. The application looks and feels like a native Handheld application, so the learning curve is minimal. Designed by practicing physicians, you capture data easily as you see patients in a way that feels natural to you.
  • Universal functionality.  We designed the application to be useful for any medical practitioner anywhere in the world. PocketPractitioner can be used by physicians or home health providers, in urban medical centers or in rural care.
  • Platform independent  You control your data, which is especially helpful if you see patients in more than one institution. Import and export functions allow integration with other business applications.
  • Applied Medical Informatics.  PocketPractitioner evolved from a Masters thesis  to a sophisticated Handheld application today.  Our goal is to maintain a high standard of excellence in all aspects of product design and implementation.

PocketPractitioner Professional is our Handheld versions.

 

PocketPractioner Professional:  Patient Tracking

·         Track patients in any clinical setting, sort patients alphabetically or by location, filter by location or activity status, and automatically purge inactive patients.  A check box in the patient list lets you know who has been seen on rounds.

  • Record patient demographic data and other clinical information, including patient diagnoses and medications.  A notepad for freehand notes is included.
  • Create patient notes, including daily progress notes and on-call notes. A powerful note form generator is included.
  • Maintain  customizable diagnosis and medication lists, including a note field for each record.  This is useful for recording clinical pearls which can later be accessed at the point of care..

 

PocketPractitoner Professional:  Charge Capture and Export & Print

  • Capture charges easily at the point of care.
  • Integrate seamlessly with the tracking features listed above.
  • Export charges and notes to Palm Memos and print from the Handheld or the PC.
  • Link diagnosis and procedure codes effortlessly.
  • Eliminate the need for complex coding calculators.  When you select a procedure or ICD code, the full description will appear, allowing much faster data entry.
  • Customize your procedure and diagnosis codes and categories. and sort your codes by description or number.
  • Custom Primary Care 2006 ICD-9-CM code set.
  • All codes sets are current, accurate and precise, allowing for prompt payment of charges.

 

PocketPractitioner Office is our Professional Plus Desktop version. This product contains the complete Handheld application, a complete Desktop application, and procedure and ICD-9-CM. This version offers a rock-solid business application built on Microsoft Access (runtime included), designed to keep track of billing for small and large organizations alike, at a fraction of the cost of comparable solutions. Designed for any medical practitioner in the world, and accepting any diagnosis or procedure coding system, this is a unique and versatile product.

 

Major Desktop functions:

  • Complete Desktop application  with Access runtime.  Enter demographic data on the PC and print reports to any printer.
  • Extensive reporting capabilities.
  • Import functions for lists of patients, diagnoses, medications and procedures. You can import codes specific to your specialty or country.
  • Export charges and notes in Microsoft Word or Excel format for printing or email.

 

Both versions will accept custom codes from any other billing system.

Terminology

It might help to define a few terms.

  • Pocket / Handheld: A small handheld computer, usually small enough to place in a shirt pocket. For now, we are developing for the Palm Operating System. A Pocket PC version is in development.
  • Practitioner: Any medical provider, including physicians, nurses, dentists, physical therapists, chiropractors, social workers, psychologists, etc.
  • Patient: Any individual cared for by a Practitioner. Feel free to substitute “Client” or other appropriate term.
  • Palm: A handheld computer utilizing the Palm Operating System.
  • PC: Personal Computer utilizing the Windows Operating System.
  • HotSync: When you place the Palm in its cradle and press the HotSync button, information on the Palm is synchronized with data on the PC. It is also possible to perform a wireless HotSync if your PC and Palm are configured appropriately.
  • Access: A software database program by Microsoft. Your patient information on the PC is stored in an Access database, and a runtime version of Access is included with the Office version.
  • Procedure:  A service or procedure rendered to a patient.
  • Charge:  A patient procedure plus a patient diagnosis.

System Requirements

  • PocketPractitioner Professional

·         A device compatible with the Palm Computing Platform with version 3.5 or higher. These devices include 3Com’s line of Palm products, all Handspring products, Symbol Technologies SPT family of devices, the IBM WorkPad PC Companion, the Franklin Day Planner, the Sony Clie, Handera, and others.

·         PocketPractitioner Office

    • Microsoft Windows 95, Windows 98, Windows NT, Windows ME, Windows 2000, or Windows XP.
    • A device compatible with the Palm Computing Platform as noted above.

Installing PocketPractitioner

CD Version

Place the CD in your computer. If the install program does not start automatically, go to the Start button, click "Run...", and then type "D:\setup.exe", where D is the name of your CD drive (the letter may vary). You may also go to "My Computer", open the CD drive, and double-click "setup.exe".

Download Version

Download the appropriate file from http://www.pocketinformatics.com , or from any of our download sites, and double-click on the downloaded file.

All Versions

You will be guided through the installation process. If you are upgrading your program, be sure to HotSync your Handheld before installing the new software.

 

If you have more than one user on the same PC, you will need to set up a different folder for each user. This process is described later.

Updating to the newest version of PocketPractitioner

This product will be continually enhanced. You can always download the most current version from our web site, and you can upgrade to more advanced products at any time.

 

Be sure to HotSync before you update your application, and, if you have the Office version, make a copy of My Data.mdb. (See Backup and Restore.)

How to Register PocketPractitioner

You have 14 days to register your Handheld.

Download Version

You may obtain a registration key at any time by following the steps listed on our web site at http://www.pocketinformatics.com .

 

Customer Support

Please send any comments or questions to support@pocketinformatics.com. We will try to answer all questions within 24 hours.

2. A Quick Tour of PocketPractitioner

Patient List

When you first open PocketPractitioner on the Handheld, you will be in the Patient List. Your initial selection is for “<All>” patients, and the patients are sorted in alphabetical order.

Menu

  • Tapping Palm Menu button brings up the PocketPractitioner Menu..
  • Record
    • The top items are the clinical lists: Diagnosis List, Medication List, Procedure List, Modifier List, Practitioner List, and Insurance List. Tapping any of these items takes you to the appropriate form
    • You can sort your patients by tapping Sort by Name or Sort by Location.

·         Tapping "Export..." takes you to a form for exporting records to the Palm Memo Pad.

    • Tapping "Purge..." takes you to a form for easily deleting patient records.
    • Tapping “Clear (*)” will clear the “*” from all patients currently displayed. (The * can be used to indicate that a patient was seen on any given day.)
  • Edit. This is the standard Palm Edit menu.
  • Options
    • Help... This displays the Help information.
    • Preferences...

·  Default. Select the patient view you would like to see first when you tap a patient name from the Patient List.  The default is "Demographics". You should probably not change this until you are fully aware of the fields in the Demographics view, as they add significant functionality to the program.  However, if 90% of your time is spent entering charges, for example, changing the default will result in two less taps per charge entry.

·  ADD ICD-9-CM 2006 Codes. Selectively add diagnosis codes from 400 of the most common ICD-9-CM codes.

·  Add Procedure Codes. Selectively add procedure codes.

Password.  This follows standard Palm conventions for setting a password specific for PocketPractitioner.  This is an important element for HIPAA compliance.

·  Numeric Keyboard. When ENABLED, the numeric keyboard will pop up in the Patient SSN, MRN, HomePhone and WorkPhone fields.

·  Backup. (Office version only).  The PocketPractitioner HotSync conduit transfers data from the Handheld to the Desktop version, but it does not backup the files automatically in the Palm backup folder.  When ENABLED, the files will backup with each HotSync, allowing for an automatic restore process if you have a hard reset or your Handheld runs out of power.  This is strongly recommended.  However, if you have an alternative backup program, and would like to have a shorter HotSync process, this function can be DISABLED.

  • Registration... This takes you through the registration process or shows your registration information.
  • Info... When you see the Info button within PocketPractitioner, you can tap it to link to any database that you have installed on your Handheld from Lexi-Comp, including Lexi-Drugs, Lexi-Infectious Diseases and Griffith's 5 Minute Clinical Consult. 
  • Purge... The takes you to a form that allow you to auto-delete all records or those records in the "Unfiled" location.
  • About PocketPractitioner... This displays information about your current version.

Location

Tapping the Location drop down list brings up a list of current location choices. Tapping any location finds patients for that location only.

 

The system locations are as follows:

  • <Active>: All patients that are not in the Unfiled location.
  • <All>: All patients.
  • New: All newly created active patients that have not yet been assigned a location. When you add patients from the PC, they will all be assigned the “New” location. We designed this function for several reasons:
    • We wanted to allow users to change their locations to suit their individual needs, so users may not have identical location names in their lists. This will become more even important when we implement “beaming” in a subsequent version of PocketPractitioner.
    • We did not want to give it the value of “Unfiled”, as we wanted our new patient to show up on the “<Active>” list.
    • Assigning the location as “New” encourages the provider to open this record and change the location as he/she is entering other information.
  • Unfiled: Patients that are inactive, but that are kept on the Palm (not deleted).
  • Edit Locations…: Allows creation, modification and deletion of locations.

Look Up

  • This functions similarly to the Palm Address Book Look Up function. Note that when you start typing the last name, the location changes to <All>.
  • This function works the same in all lists.

Find

  • Tapping the Find button on the Palm brings up the “PocketPractitioner Find” form. Type any portion of a name or number or a valid date, select the field you want to search on from the drop-down list, and press “Find” (or “Cancel” to return to your previous position.) PocketPractitioner will find all entries on the Palm that match your request.
  • This function works the same in all lists..

New

Tap to create a new patient.

Patient

Tap any patient to go to the “Patient Edit” form. This is where the action begins.

Patient Edit

Location

Tap any location to assign the location to the patient. Select “New” if you do not know the location, “Unfiled” if this is an inactive patient , and “Edit Locations…”, if you want to change the list of Locations.

Last name

The Patient List is sorted alphabetically by last name, then first name.

First name

Middle name

DOB

Date of Birth: Tap the drop list (the downward-pointing triangle) to show a list of decades for quick data entry.  For example, tapping "1920's" will take you to 1/1/1925. Tapping the date field brings up the Palm Calendar.

MRN

Medical Record Number: This is a KEY field, which means that if a new patient is added to PocketPractitioner on the PC with the same MRN that you have entered on the Palm, the Palm demographic data may be overwritten by the PC data. This allows you to simply enter your new patient as you are making rounds as “Smith”, adding only the MRN. If your staff is also tracking your admissions, the next time you HotSync the demographic data may be updated, but the clinical data will be untouched. If you decide not to implement this feature, your data will be untouched by the HotSync event.

SSN

Social Security Number: This is also a KEY field, as noted above. Users not in the USA may use this for any other patient identifier.

Home

Home phone

Work

Work phone

Loc 2

Location 2. When the patients are sorted “By location” in the Patient List, they are sorted first by Location and second by Location 2. This allows you to start your rounds at the top floor and work down, or you can experiment with other naming conventions to make this work for you. For example, if you do a lot of outpatient surgery in the Ambulatory Surgery Department, you may want to give all patients the Location 2 name of “ASD”.

Sex

Check the appropriate box. This field was added as it is often a component of the patients Unique Identification Number or as an identifier in a electronic medical record.

(*)

Placing a check mark in this box places a “*” in the Patient List. You can use this for any purpose you wish, but typically it would be used after you have seen the patient for the day, or perhaps after you have entered the appropriate procedure code.

Clear (*)

Go back to the Patient List by pressing the Back Arrow button and tap the Palm Menu button to bring up the PocketPractitioner Menu. If you tap “Clear (*)”, the “*” are cleared from the location that you are currently viewing. If you want to clear all “*”, then chose <All> for the location.

View Selector

This will be described below.

Details

Tapping takes you to another form to continue data entry.

Provider

This field should contain the name of the provider of services (typically, you). New patients will automatically be assigned to the last provider that was chosen.

Primary

This is the patient’s Primary Care Practitioner or PCP. For billing purposes, this is also the Referring Practitioner.

 

You can enter the name directly or tap the drop down button for a list of practitioners. From this list, you can perform a Look Up to view the practitioner you would like to add. When you tap the name, you will be taken to another form. Tap “Add” to add this practitioner to your patient’s form.

Insurance

This is the patient’s medical insurance. You can enter the insurance directly or tap the drop down button for data entry as noted above.

Comment

Use this field to make additional notes related to this patient. You may want to add demographic information that is not included in other fields. For example, a trauma surgeon may want to record the patient’s drivers license number. Clinical notes may be created in the Patient Note List, which is described below.

Start date

Tapping this field brings up the Palm Calendar. The start date is the date the patient was entered on the Palm, and it will be auto-entered as the patient record is created.

End date

Data entry is as noted above. The end date is the date the patient encounter was completed. The procedures should be complete and the patient can potentially be removed from the Palm. Entering a date makes “Charges complete” visible. You can clear the End date by tapping the label.

Charges complete (C)

Check this box if all charges have been entered for all dates between the Start date and the End date. A “C” is placed in the Patient List.

 

If you have the Office version, checking the box makes “Delete after HotSync” visible. Then, after the next HotSync, the patient will remain on the Palm, the charges will be removed from the Palm and saved on the PC , and the “C” is replaced by an “X” in the Patient List.

Delete after HotSync (D) (Office version only)

Check this box to delete the patient and all associated lists from the Palm and save it on the PC at the time of the next HotSync. A “D” is placed in the Patient List.

Delete

Tapping shows up a dialog box confirming that you want to delete the record. If you tap “Ok” then the patient and all associated records will be removed from the Palm and all data entered from the time of the last HotSync will be lost.

Drawing

Tapping shows a form where you can write or doodle on the screen. The date is auto-entered. Tap "Erase" to empty the form. When you click Done, the button changes to "Drawing!" if you have written on the form.

Done

Tap to return to Patient Edit.

View Selector

Tap the View Selector in the left lower corner of the screen.  The views include Demographics (also called Patient Edit) and the patient clinical lists: Diagnoses, Medications, Charges, and Notes.

Export

Tap “Export...” in the Record Menu to export Charges and Procedures for this patient only to the Palm Memo Pad.

Back Arrow

Tap to return to the Patient List from any view.

PocketPractitioner Diagnosis List

Before we examine the patient lists, it is necessary to take a quick look back at an earlier topic. Return to the Patient List by tapping the Back Arrow button and tap the Menu button. You will see the six lists maintained within PocketPractitioner. Tap “Diagnosis List”.

LookUp and Find.

As in the Patient List, you can use the Look Up or Find methods to find diagnoses.

Categories

In addition to Look Up and Find, Categories offers a way for you to quickly display those procedures that you use commonly. You can assign a category in Edit Diagnosis by tapping the procedure and then “Details”.

Back Arrow

Tap to return to the Patient List.

Menu

Tap "Diagnosis List" or the Menu key to open the Record Menu.  You will see that you can Sort your list by Diagnosis or Code or elect to Show either Diagnoses and Categories or Diagnosis and Codes.  As in the Patient List, you can quickly delete records with "Purge Diagnoses...".  (You can restore the records easily as noted below.)

 

Lastly, if you tap "Add ICD Codes", you will see the following message, "The records displayed are not currently in your Diagnosis List. You may edit the fields and then add them selectively or all at one time. You may repeat this process at any time."

 

When you first install the program, the list will be loaded with approximately 400 primary care diagnosis codes.  However you may delete or purge some of the diagnoses, and you may decide later to reload the diagnoses or check for new codes.

 

Use the arrows to scroll back and forth through the list, adding the codes as you wish. Diagnoses on your list with matching codes will not be displayed. Although this process may take you some time, it is much faster than adding the items manually. If you have the Office version, you can perform the same functions on the PC.

New

Tap to create a new diagnosis.

Diagnosis

Enter the diagnosis and code and change the category as desired. You also have a note field, and you can write anything you would like about this topic. You can enter up to 2000 characters, or about six screens of information, in this field. This makes it ideal for taking notes during lectures or to make quick notes as you are reading the literature. (Does this remind you of the notebook that you carried in your lab coat during your training?).

Back

This returns you to the Diagnosis List.

Info

If you have a product from Lexi-Comp on your Handheld, this button will take you directly to that database without leaving PocketPractitioner.  You will be presented with a choice of Lexi databases, if you have more than one, and after your selection you will be taken to the closest alphabetical match to your Diagnosis.  In the Diagnosis List the Lexi button works best with Griffith's 5-Minute Clinical Consult or Lexi Infectious Diseases.   When you want to return to PocketPractitioner, tap the Lexi Menu and tap "Quit".

Delete

Tap if you would like to delete a diagnosis. A screen will pop up to confirm your decision.

 

Stop! You may be thinking that this is entirely too much data entry for the Palm. We could not agree more, which is why almost all list maintenance is automated on both the Handheld and the PC, as described later.

PocketPractitioner Medication List

Go back to the Patient List, tap the Menu button and tap “Medications”. Everything is the same as above, except that there is no code for medications and no categories.  In the Medication List the Info button works best with Lexi-Drugs, Nursing Lexi-Drugs, Pediatric Lexi-Drugs,  Dental Lexi-Drugs and Natural Products.

PocketPractitioner Procedure List

Go back to the Patient List, tap the Menu button and tap “Procedures”. Everything is the same as above.  In the Procedure List, the Lexi button works best with Griffith's 5-Minute Clinical Consult.  For example, "Appendectomy" will find "Appendicitis".  Even if there is not an exact match, you can use the Info button to jump to Lexi, look up information, and then return to your previous location.

Return to Patient

Go to the Patient List by pressing the Back Arrow button and select any patient.

Diagnoses

Tap the View Selector  in the lower left corner of the screen and then tap“Diagnoses” and you will go to the Diagnoses form where the diagnoses for this patient are displayed. To distinguish the patient Diagnoses from the PocketPractitioner Diagnosis List, the patient’s name is displayed in the label. You will find this convention repeated throughout the program.

 

Tapping any item takes you to the Patient Diagnosis form.

Patient Diagnosis Form

You can edit the Diagnosis or Code, and you can enter a patient specific note. 

  • Details: The Details button takes you to the Diagnosis Edit form linked to your Patient Diagnosis.  Here you can view your personal notes link to Lexi-Comp products that you have installed on your Handheld, as noted above.
  • Delete: Tap if you would like to delete a patient diagnosis. A screen will pop up to confirm your decision.
  • Done:  Tap to return to patient Diagnoses.

View Selector

Tap any item to move to another patient view.

New

Tap “New” to add a new diagnosis to your patient. Not surprisingly, you find yourself back at the PocketPractitioner Diagnosis List. It functions exactly as before, with the following exceptions.

  • Back Arrow: This will return you to patient Diagnoses without adding a diagnosis.
  • Add: When you select a diagnosis, the Add button becomes visible. As you would expect, this adds the diagnosis to your patient and returns you to the Patient Diagnosis form.  You can add a patient-specific comment if you like, then tap Done to return to the Patient Diagnosis List.

Medications

Tap the View Selector and “Medications” and you will go to the patient Medications list. The list displays the medication name and  Sig. Tapping the medication takes you to the Patient Medication form.

Show table

Tapping shows a table to assist data entry for the Sig. “Hide table” removes

the table.

Charges

Tap the View Selector and “Charges” and you will go to the patient Charges list. Everything is the same as above, with the following exceptions:

Menu

If you tap the Patient Name or the Palm Menu button, you will see the following options:

·         Sort by Date

  • Sort by Reverse Date

Charge List

Tapping the charge brings up the Patient Charge form.

Charge Form

  • Date: The date of the charge. Tapping this field brings up the Palm calendar.
  • Time: The time of the charge. Tapping this fi