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ULTIMA*DCF ULTIMA*DCF CHOTS (component health-care off-theshelf) solution is dedicated to children and adolescent psychiatric care institutions of the Departments of Children and Families. Copyright © 2004-2011 ITC Software All rights reserved ULTIMA*DCF CHOTS (component health-care off-the-shelf) solution is dedicated to children and adolescent psychiatric care institutions of the Departments of Children and Families. ULTIMA*DCF CHOTS SOLUTION ULTIMA*DCF offers ten (10) components for all interested institutions. Five (5) are dedicated to the patient administration and five (5) to patient care, including comprehensive electronic patient/medical recording of patient’s treatment progress. Available Components Patient Administration Patient Care Only certified physicians, psychologists, nurses and other authorized hospital/institution staff have access to the ULTIMA*DCF application. This is enabled by activating the horizontal tabs according to each user’s access privileges. USER’S SIGN ON Only certified physicians, psychiatrists or psychologists have access to the ULTIMA*DCF applications enabled by activating the horizontal tabs according to each user’s access privileges. Physicians Nurses and other authorized hospital/institution nursing staff have access to the ULTIMA*DCF application, enabled by activating the horizontal tabs according to each user’s access privileges. Nurses Authorized hospital/institution staff have access to the ULTIMA*DCF application, enabled by activating the horizontal tabs according to each user’s access privileges and HIPAA guidelines. Technologists/Administration The HIPAA certified security officer, usually a DBA (database administrator), is authorized to assign user’s roles, access to specific applications and user’s password. HIPAA COMPLIANT ACCESS The ULTIMA*DCF scheduler is a unique application seamlessly integrated with other system components. SCHEDULING This form is used by the clinic front desk to capture data from new patients, who’s referring physician usually contacts the clinic by phone. SCHEDULING The Physician and Staff listing allows the booking staff the selection of the requested or least busy physician, psychologist or other mental caregiver. SCHEDULING The appointment calendar of the selected surgeon gives the staff a number of choices: open the data entry by a click on the ‘zoom’ square to the right of the appointment time (see next form to enter appointments). The daily, weekly or monthly schedules can be viewed by a single click of the mouse at the left. SCHEDULING This is the appointment entry form that allows the entry of a new appointment or the cancellation of an appointment and assigning the priority of the appointment by the established color codes. SCHEDULING The ULTIMA*DCF Scheduler features both the weekly and monthly appointment reviews. SCHEDULING This form is an online report for the medical records staff. SCHEDULING ULTIMA*DCF includes a number of reports and statistical analyses for the clinic management. SCHEDULING A click on the Registration button displays the child’s registration and admission component menu. CHILD REGISTRATION The hospital admission menu consists of six vertical tabs for easy access to registration components and to the room/bed allocation. CHILD’S ADMISSION Patient demographics, mailing address, phone information and patient’s referring physician data are entered into this form. Some of the data are selected by a simple click at the so-called LOV icon. FAST AND EASY CAPTURE OF DATA The Patient Family Contacts form captures the important family or child’s guardian data. FAMILY CONTACTS The information about the insurance coverage is entered in two forms, primary and secondary insurance, if any. CHILD’S PRIMARY INSURANCE The information about the insurance coverage is entered into two forms, primary and secondary insurance, if any. SECONDARY INSURANCE The assignment of the patient to a ward, room and bed is supported by a fully computerized bed inventory. ROOM & BED ALLOCATION The Electronic Records component consists of two groups of applications: 1) EPR and 2) Patient Intake Form. ELECTRONIC RECORDS MENU The wards/nursing stations applications are a hub of all patient care information. WARDS/NURSING UNITS The Ward Organization form is a convenient overview of the ward’s structure, by listing all rooms and beds of each ward, selected from the hospital ward listing. WARDS/NURSING UNITS The top block of the Ward Staff Scheduling form displays the managers of each ward, i.e., the chief physician and head nurse. Changes in the management staff are made by the hospital chief-of-staff who has been authorized to update this list. The second block is a list of the staff of each ward, their main responsibilities (‘Note’), and the current shift. The head nurse usually maintains the ward’s schedule. The first block is a summary view of each room. The second block displays the name of each patient, admission date, and expected length of stay (LOS). An LOV button selects the name and unique ID of the patient’s attending physician. Then the severity rate, patient diet and differential diagnoses are entered, marking the primary diagnosis. The third block is used for a patient’s discharge; indicating the reason and discharge summary. The command button ‘Discharge’ activates a number of important transactions, namely the transfer of all patient electronic records into an ARCH_ database for billing, reporting and statistics, as well as updating the electronic bed inventory. The S-O-A-PE methodology and format are used as a common denominator for every ward’s electronic recording. In this manner it is possible to enter all Patient Treatment Progress Notes generally, yet specific to each ward.The ‘Open S-O-A-PE’ button enables the ward staff to have fast, online access to the patient’s treatments, orders and results. The powerful Oracle 9i/10g database technology acts as an integrator of the current ‘legacy’ systems throughout your hospital. Patient’s chart and name, selected from the ‘List of Resident Patients’ are displayed automatically. The date and time are displayed by default. The purpose of the Subjective notes is to record a patient’s subjective communication or complaints to the nursing staff (remember: ‘what is not recorded – does not exist’). The entry of these subjective data are supported by two options: 1) the use of an LOV (list of value) button which displays a pull-down list of the most frequently used subjective patient complaints, and 2) the display of an edit window (called modal) for the entry of additional, specific subjective information. The date, time, and the nurse’s internal code are mandatory items for each entry. The name of the nurse responsible for the entry is displayed when the nurse’s code is entered. The ‘Save’ button secures the entry of the information into the database. The entry of the objective data is similar to entry of the ‘S’ section data; the nurses are aided by two buttons, Search (LOV pull-down list) and Edit, in order to make the recording of data acceptable and simplistic. The purpose of the Objective notes is to record all ‘objective’ data (remember again: ‘what is not recorded – does not exist’), mainly vital signs and measurements, and important patient’s behavioral and abnormal test results. Each nurse has convenient access to a patients’ laboratory test results, thus having a more comprehensive understanding of a patient’s medical situation, usually reserved for physicians. There are two options for the capture of laboratory test results: 1) transferred from the clinical laboratories, and 2) entered by the ward staff (e.g., a ward clerk) from the paper printouts. LABORATORY TESTS The patient’s attending physician, after reviewing and assessing the subjective and objective data, both in his/her home office or at the time of the visit, has a considerable amount of pertinent information at his/her ‘finger tips’ – just a click away for the following: 1) patient health care history, 2) patient physical examination/review of systems, 3) medication orders and administration, and 4) orders of laboratory tests, diagnostic examinations and treatments, as well as physiotherapy and other therapies. The entry of the attending physician’s comments and instructions to nursing teams are aided by easy to use, and ward care specific, pull-down lists of free text (Search). The physician and the ward staff do not need to know the numerical/alphanumerical codes that are used, therefore they are not displayed. These are listed only as unique identifiers and primary keys in the Oracle database. An Edit button displays a special ‘zoom’ window for the entry of a specific physician’s treatment notes. The patient’s medical history form, displayed by a click on the Pt Health History button, consists of four blocks: 1) Patient identification (the chart number and full patient name are displayed automatically), 2) Past diseases (the name and ICD9 code are entered by the ward staff from the LOV – list of values – pull down listing of codes entered during the installation of the system), 3) Medications are entered based on the patient’s own recollection, and 4) As well as Allergies mainly drug and food adverse reactions. All entered data and updates are stored in the patient’s electronic record by a click of the Save button. PATIENT’S ASSESSMENT The structure and contents of the block ROS (review of systems) is adjustable for each specialty. A click on the ‘Zoom’ square displays a window, called a ‘modal’, that enables the entry of longer text. The length of the text is also flexible depending upon the needs of each medical specialty. Entry and Review of PE The physician selects the drug from the approved list of drugs – hospital drug formulary – from a pull down list. The National Drug Code (NDC), generic name, strength and dosage are displayed automatically. The physician enters only the quantity, frequency and route of drug administration. A check off box informs the pharmacy if there is a requirement to prepare a Medication Administration Record (MAR) for this prescription. The physician is able to access the preferred Drug Consultant available on the Internet or hospital’s intranet before approval is given to print the MAR or to send the prescription to the hospital pharmacy. The physician’s electronic signature (full name) is mandatory data to be entered. Without it the Save button will not function and the prescription(s) will not be saved in the patient’s electronic medication profile . DRUG WEB CONSULTANT OPTION www.rxlist.com is an example of a ‘free of charge’ Internet RxList. In addition to the Rxlist Web site, there are a number of highly reliable drug consultant sites, such as Medscape, Electronic Medicines Compendium (eMC), Scholz Healthcare, Drug InfoNet, RxMed, RxCentric, Drugs.com, Consumer-Oriented Databases, etc. A simple click on the Treatment Orders button displays a menu with three vertical tabs of the most frequently ordered tests and examinations, namely Laboratory Tests, X-ray/Diagnostic Imaging, and Therapy Orders. Each of the order forms/requisitions has an identical layout of two blocks: 1) A list of approved tests, examinations and therapies, 2) A list of all orders placed for the selected/designated patient during his/her hospitalization. A check off box indicates if the results have arrived or are available. A single click on the Treatment Orders button displays a menu with three vertical tabs of the most frequently ordered tests and examinations, namely Laboratory Tests, X-ray/Diagnostic Imaging, and Therapy Orders. Each of the order forms/requisitions has an identical layout of two blocks: 1) A list of approved tests, examinations and therapies, 2) A list of all orders placed for the selected/designated patient during his/her hospitalization. A check off box indicates if the results have arrived or are available. A simple click on the Treatment Orders button displays a menu with three vertical tabs of the most frequently ordered tests and examinations, namely Laboratory Tests, X-ray/Diagnostic Imaging, and Therapy Orders. Each of the order forms/requisitions has an identical layout of two blocks: 1) A list of approved tests, examinations and therapies, 2) A list of all orders placed for the selected/designated patient during his/her hospitalization. A check off box indicates if the results have arrived or are available. The last form of the S-O-A-PE electronic records is the Patient Plan and Education (PE) section. The entry of the Nursing care plan based on NANDA nursing diagnosis is optional. For more information visit: http://www.nanda.org/ PATIENT CARE PLANS & EDUCATION In all ULTIMA*DCF forms the entry of data is simplified by the deployment of pull-down list of values (LOV). A single click at the LOV icon attached to most fields, activates the underlying coding structure database schemas - to enable the operator the selection of data for the field. There are four groups of codes included in the ULTIMA*DCF Code Menu. ULTIMA*DCF - Codes General codes used by the registration staff are simple to maintain. Here are examples of Citizenship and Ethnic/Race codes. ULTIMA*DCF – General Codes General codes used by the registration staff are simple to maintain. Here are examples of Language and School Grade codes ULTIMA*DCF – General Codes General codes used by the registration staff are simple to maintain. Here are examples of Religion and State codes ULTIMA*DCF – General Codes Ward and room codes maintain the list of all hospital units and rooms including the charge/diem. ULTIMA*DCF – Spec. Codes List of physicians licensed (approved) by the hospital and their specialties are maintained by these two forms. ULTIMA*DCF - Spec. Codes Nursing staff and their certified/official specializations are entered and maintained by these forms. ULTIMA*DCF - Spec. Codes Nursing position codes could be expanded for the HR and payroll applications. ULTIMA*DCF - Spec. Codes These are examples of subjective and objective typical statements or complaints used for entry into the Subjective and Objective sections of S-O-A-PE electronic patient treatment progress notes. ULTIMA*DCF - Spec. Codes Medical assessments and nursing plans, as well as patient education statements, are used for entry into the Assessment and PE sections of the S-O-A-PE electronic patient treatment progress notes. ULTIMA*DCF - Spec. Codes ICD-9 CM codes as well as CPT (‘Current Procedural Terminology’ by the American Medical Association) are maintained for the US institutions. For installations outside the US the system coding schemes include ICD-10 and other codes for reimbursement, e.g., fee codes. ULTIMA*DCF – Diag. Codes The patient’s intake form is a unique component of ULTIMA*DCF. It’s main goal is to enable a thorough assessment of the child’s or adolescent’s status and admission to the treatment facility. It also creates a powerful database for statistics and research as well as flexible adjustment of the questionnaire for each psychiatric facility. ONLINE CHILD’S INTAKE FORM The Patient Intake Form’s first tab opens the section of the patient’s demographic data, usually already entered during the child’s registration. If the registration has not been done, the data from the data captured here will be available at the time of registration/admission. ONLINE CHILD’S INTAKE FORM The information about the insurance coverage is entered in two forms, primary and secondary insurance, if any. ONLINE CHILD’S INTAKE FORM The information about the insurance coverage is entered in two forms, primary and secondary insurance, if any. Note that the date, chart number and child’s name are displayed by default. ONLINE CHILD’S INTAKE FORM The fourth data entry tab opens the section of patient’s information about parents, mother and father in two separate blocks. ONLINE CHILD’S INTAKE FORM The Siblings data entry tab opens the section of the patient’s information about any siblings, as well as about other members of the household. ONLINE CHILD’S INTAKE FORM The birthmother pregnancy problems required answers are aided by lists of optional statements (e.g., YES, NO) that are displayed by a click on the ‘down’ arrow icon. Note that the date, chart number and child’s name are displayed by default. ONLINE CHILD’S INTAKE FORM The child’s delivery required answers are aided by lists of optional statements (e.g., YES, NO, NATURAL, HOSPITAL, etc.) that are displayed by a click on the ‘down’ arrow icon. ONLINE CHILD’S INTAKE FORM The infant’s data entry is also aided by lists of optional statements (e.g., YES, NO) that are displayed by a click on the ‘down’ arrow icon. ONLINE CHILD’S INTAKE FORM The infant’s development data entry is also aided by lists of optional statements (e.g., YES, NO) that are displayed by a click on the ‘down’ arrow icon. ONLINE CHILD’S INTAKE FORM The child’s behavior data entry is also aided by lists of optional statements (e.g., YES, NO) that are displayed by a click on the ‘down’ arrow icon. ONLINE CHILD’S INTAKE FORM A child’s medical history covers mainly allergies and adverse drug reactions. A child’s physician as well as the diagnosis are included in this section of the intake questionnaire. ONLINE CHILD’S INTAKE FORM This section of the Patient Intake Form covers the child’s family tree and the health status of each family member. ONLINE CHILD’S INTAKE FORM The Pharmacy component is an option for larger hospitals. This menu – Introduction - consists of nine applications accessed by a click on the vertical tabs. ULTIMA*DCF PHARMACY The Patient Data Entry form is a duplicate copy of the patient registration form. This is an option for a stand-alone pharmacy. ULTIMA*DCF PHARMACY The Incoming Drug Orders form lists all prescriptions sent from the hospital wards. ULTIMA*DCF PHARMACY All orders/prescriptions of drugs are listed for the dispensing approval (OK box) by the pharmacist. Details of each approved item are displayed in the second block. ULTIMA*DCF PHARMACY The Patient Medication Profile, consists of four blocks of important information: 1) Patient’s ID code and full name, 2) Patient’s allergies and adverse drug reactions, 3) Listing of all current drugs and medications with three check off boxes: A = approved, D = dispensed, X = not approved, 4) Item details. ULTIMA*DCF PHARMACY The medication administration record (MAR) is prepared by the hospital pharmacy at the request of the physician who prescribed the medication. The form consists of four blocks: 1) Patient’s ID, 2) A list of current patient’s drugs/medications, 3) MAR plan prepared by the pharmacy 4) Actual administration. ‘Note’ fields could be displayed in full by a click on the ‘Zoom’ icon. ULTIMA*DCF PHARMACY The Inventory Stock Control offers the hospital pharmacy a powerful online review of all items including the quantity on hand (QOH) and quantity on order (QOO) as well as the total inventory value based on the hospital internal costing guidelines. Details of each stock item are displayed in the second section of the form. ULTIMA*DCF PHARMACY A complete log of all transactions (opening balance, issued, received, returned, physical inventory count + -) enables the pharmacy management an online review of the stock movement. ULTIMA*DCF PHARMACY The Review of Drug Orders is a listing of all items on order from suppliers. The entry of new orders and the electronic order, electronic data interface (EDI), deployment is done by a check off of the Act (activate) box. Details of each purchase order are displayed in the lower section of this form. ULTIMA*DCF PHARMACY The hospital pharmacy is responsible for the entry and maintenance of coding schemes of all applications. ULTIMA*DCF PHARMACY - Codes The Drug Formulary, i.e., a list of approved drugs and medications, is the foundation of the hospital pharmacy management, as well as drug orders/prescription from physicians. It contains all information for drug orders from suppliers, plus the maintenance of stock. ULTIMA*DCF PHARMACY - Codes The pharmacy has an option of using traditional abbreviations derived from Latin or their own codes, e.g., instead of ACL – BL = Before lunch, etc. ULTIMA*DCF PHARMACY - Codes The Drug Administration Route codes are based on the pharmacy internal coding, e.g., RTE01, etc. It is important to note that these alpha-numerical codes are only for the database unique item’s identification. ULTIMA*DCF PHARMACY - Codes This is an example of drug manufacturers codes, usually well established within the pharmaceutical professional community. ULTIMA*DCF PHARMACY - Codes The details of drug suppliers (primary, secondary, etc.) are captured and maintained by this form. ULTIMA*DCF PHARMACY - Codes One of the most important issues of any electronic hospital system is the reliability and confidentiality of the sensitive patient information. Oracle9i/10g database systems are one of the, if not the best in the world and fully compliant with HIPAA requirements. POWERFUL ORACLE9i/10g DATABASE U_DCF_SECOND_INSREG PT_ID: INTEGER NOT NULL (FK) SECOND_INS_ENTRY_DATE: DATE NULL SECOND_INS_NUMBER: VARCHAR2(20) NULL SECOND_INS_PLAN_NUMBER: VARCHAR2(20) NULL SECOND_INS_HOLDERNAME: VARCHAR2(50) NULL SECOND_INS_DOB: DATE NULL SECOND_INS_SEX: VARCHAR2(10) NULL SECOND_INS_EMPLOYER: VARCHAR2(30) NULL SECOND_INS_NAME: VARCHAR2(50) NULL SECOND_INS_ADDRESS: VARCHAR2(50) NULL SECOND_INS_PHONE: VARCHAR2(15) NULL SECOND_INS_CONTACT: VARCHAR2(30) NULL U_DCF_PRIM_INSREG PT_ID: INTEGER NOT NULL (FK) INS_SEQ_NO: NUMBER NULL INS_ENTRY_DATE: DATE NULL INS_SIN: NUMBER NULL INS_HOLDER_NAME: VARCHAR2(50) NULL INS_RELATIONSHIP: VARCHAR2(1) NULL INS_HOLD_ADDRESS1: VARCHAR2(30) NULL INS_HOLD_ADDRESS2: VARCHAR2(20) NULL INS_HOLD_ADDRESS3: VARCHAR2(20) NULL INS_HOLD_ADDRESS4: VARCHAR2(20) NULL INS_HOLD_PHONE: VARCHAR2(15) NULL PRIM_INS_GRP_ID: VARCHAR2(20) NULL PRIM_INS_PLAN_NUMBER: VARCHAR2(20) NULL PRIM_INS_GRP_HOLDER_DOB: DATE NULL PRIM_INS_GRP_HOLDER_SEX: VARCHAR2(10) NULL PRIM_INS_GRP_HOLDER_EMPLOYER: VARCHAR2(30) NULL PRIM_INS_NAME: VARCHAR2(50) NULL PRIM_INS_ADDRESS: VARCHAR2(50) NULL PRIM_INS_PHONE: VARCHAR2(15) NULL PRIM_INS_CONTACT: VARCHAR2(30) NULL SECOND_INS_FLAG: VARCHAR2(5) NULL U_DCF_USER_REG USER_ID: INTEGER NOT NULL ACCOUNT_CODE: VARCHAR2(15) NOT NULL USER_NAME: VARCHAR2(30) NOT NULL PASSWORD: VARCHAR2(15) NOT NULL OLD_PASSWORD: VARCHAR2(15) NULL ROLE_CODE: VARCHAR2(5) NULL FUNCTION_CODE1: VARCHAR2(5) NULL FUNCTION_CODE2: VARCHAR2(5) NULL FUNCTION_CODE3: VARCHAR2(5) NULL FUNCTION_CODE4: VARCHAR2(5) NULL ENTRY_DATE: DATE NULL U_DCF_MPIREG PT_ID: INTEGER NOT NULL PT_CODE: VARCHAR2(15) NOT NULL PT_NAME1: VARCHAR2(30) NOT NULL PT_NAME2: VARCHAR2(20) NULL PT_NAME3: VARCHAR2(20) NULL PT_NAME4: VARCHAR2(20) NULL PT_REGNO: NUMBER NULL PT_REGDATE: DATE NOT NULL PT_DOB: DATE NULL PT_SEX: VARCHAR2(10) NULL RELIG_ID: INTEGER NULL (FK) CITIZEN_ID: INTEGER NULL (FK) LANG_ID: INTEGER NULL (FK) ETHNIC_ID: INTEGER NULL (FK) GRADE_ID: INTEGER NULL (FK) PT_ADDRESS_LINE1: VARCHAR2(30) NULL PT_ADDRESS_LINE2: VARCHAR2(20) NULL PT_ADDRESS_LINE3: VARCHAR2(20) NULL STATE_ID: INTEGER NULL (FK) PT_HPHONE: VARCHAR2(15) NULL PT_OPHONE: VARCHAR2(15) NULL PT_EMAIL: VARCHAR2(15) NULL PT_MDREFER: VARCHAR2(30) NULL CONT_TXT: VARCHAR2(100) NULL CONT_ENTRY_DATE: DATE NOT NULL U_DCF_CONTACTS PT_ID: INTEGER NOT NULL (FK) CONT_HPHONE: VARCHAR2(15) NULL CONT_OPHONE: VARCHAR2(15) NULL CONT_NAME: VARCHAR2(50) NULL Model: DCF physical database model Version: 1.0 Author: Ruslan Vagizov U_CD_DCF_CITIZENSHIPLIST CITIZEN_ID: INTEGER NOT NULL CITIZEN_CODE: VARCHAR2(10) NOT NULL CITIZEN_DESCRIPTION: VARCHAR2(30) NOT NULL U_CD_DCF_STATELIST STATE_ID: INTEGER NOT NULL STATE_CODE: VARCHAR2(10) NOT NULL STATE_DESCRIPTION: VARCHAR2(30) NULL U_CD_DCF_LANGUAGELIST LANG_ID: INTEGER NOT NULL LANG_CODE: VARCHAR2(10) NOT NULL LANG_DESCRIPTION: VARCHAR2(30) NULL U_CD_DCF_RELIGIONLIST RELIG_ID: INTEGER NOT NULL RELIG_CODE: VARCHAR2(10) NOT NULL RELIG_DESCRIPTION: VARCHAR2(30) NULL U_CD_DCF_SCHOOLGRADELIST GRADE_ID: INTEGER NOT NULL GRADE_CODE: VARCHAR2(10) NOT NULL GRADE_DESCRIPTION: VARCHAR2(30) NULL U_CD_DCF_ETHNICGRPLIST ETHNIC_ID: INTEGER NOT NULL ETHNIC_CODE: VARCHAR2(10) NOT NULL ETHNIC_DESCRIPTION: VARCHAR2(30) NULL ITC Software is an advanced information technology solutions provider, focused on the global commercial and scientific markets. With over 4047 software engineers in the Americas, Europe, Russia and Asia, and a host of world-renowned scientists at, inter alia, Harvard and MIT, ITC Software’s services range from research & development in finance, bioinformatics and FEA engineering, to cutting-edge custom software development and maintenance services in most industry verticals, to the turnkey establishment of Offshore IT Centers. ITC Software has won numerous international awards and its centers are ISO 9001:2000 certified and CMMI level 4 pre-certified. Pricing is extremely competitive for both complex scientific applications such as bioinformatics and biomechanics, and commercial software development projects. We hope you enjoyed our presentation ! Please call or email us, if you have any questions, need more information, would like to embark on a research project, or require software development services Tel. +1 978 287 4855 [email protected] Become a high performance enterprise with Strategic Outsourcing, visit www.itcsoftware.com Thank you! We hope you enjoyed our presentation ! Please call or email us, if you have any questions, need more information, would like to embark on a research project, or require software development services. Thank you! ITC Software Tel. +1 978 287 4855 [email protected] www.itcsoftware.com