Subject: Patient Record Management
Effective Date: December 2015
Effective Date: December 2015
Mar 29, 2016 This is a video introduction to axium for staff. Produced by the Department of Dental Informatics at the Oklahoma University College of Dentistry. This training manual addresses: 1. Scanning exposed plates into MiPACS using the Optime scanners 2. Saving the images to local and permanent servers 3. Retrieving and viewing the images with axiUm 4. Manipulating the images in MiPACS 5. Importing and Exporting images in MiPACS 6. Quality Control 8. Troubleshooting 9.
Purpose
To establish uniform procedures detailing the responsibilities of dental providers (including Employee, Faculty, Affiliate Faculty, Pre-doctoral and Graduate Students) who administer treatment to patients of record within the School of Dentistry (herein referred to as “SOD”) to compile and maintain patient treatment records. This policy is intended to ensure that all patient recordkeeping is maintained by treatment providers at the SOD in a manner that is fully compliant with all relevant laws and regulations.
General Policy
The SOD employs a patient Electronic Health Record (herein referred to as “EHR”) system called axiUm and a patient radiograph record system called “MiPACS.”[1] Dental providers engaged in all levels of patient related clinical activity must adhere to strict policy guidelines and regulatory requirements when entering patient treatment notes and records in axiUm and MiPACS.
Such requirements also apply to approval of student notes and procedure codes compiled during clinical teaching activity. This policy sets forth: (1) rules for timely input and/or approval of patient treatment notes and procedure codes; (2) monitoring and corrective actions taken for non-compliant treatment providers; and (3) an enforcement mechanism – that will ensure that SOD remains in compliance with all applicable statutory and regulatory requirements.
Implementation
I. Legal and regulatory requirements
Washington state law governing the “Maintenance and Retention of Records” requires that dentists compile and maintain comprehensive and dated patient treatment records. The statute expressly states that, “[any] dentist who treats patients in the State of Washington shall maintain complete treatment records regarding patients treated” (Washington Administrative Code (WAC) section 246-817-310).[2] Furthermore, such treatment records, once compiled and recorded under the above provision, must be maintained in compliance with federal law governing confidentiality of patient records under the Health Insurance Portability and Accountability Act of 1996 (herein referred to as “HIPAA”).[3] Under HIPAA and the SOD’s EHR policy, the obligation to ensure patient confidentiality extends to:
“…electronic exchange [of] financial and administrative transactions [for] health claims or equivalent encounter information; [such as] health claims… healthcare payment[s]… [including] unique health identifiers… [i.e. procedure] codes… for appropriate data elements for […] transactions… [including] audit trails in computerized record systems… (HIPAA Sec.1173 (a) “Standards to Enable Electronic Exchange”).”[4]
II. Provider obligations
The following are the requirements adopted by the SOD, concerning the obligation of our providers to compile and maintain proper patient treatment records (regardless of whether the patient visit is considered a paid visit or a no-charge follow-up visit)
- Faculty – In recording treatment notes, faculty must utilize the SOAP format as stated in the SOD’s Health Information Management Policy, Section 3.1 of the Clinic Policy Manual for Faculty & Staff (herein referred to as Clinic Policy Manual). Notes must be completed, at the end of the treatment day or no later than twenty-four (24) hours following the patient appointment and in anticipation that the patient will be seen by other clinics and specialties for on-going treatment and/or for revenue cycle purposes. Please refer to the Clinic Policy manual for clarification and structure of SOAP notes. Furthermore, if scanning of patient notes, treatment plans or any other format containing information that cannot be captured in an axiUm form is used, there must be a separate fully structured and formatted SOAP note in the axiUm format within the above-mentioned time frame. In sum, all patient recordkeeping must be properly and promptly recorded in axiUm and/or MiPACS.
- Affiliate Faculty – Affiliate faculty must adopt the above-described policy utilizing the SOAP format but are required to complete and approve all treatment notes and procedure codes by the end of their assigned clinic session on the same day.
- Pre-doctoral, Graduate and Resident Students – Students engaged in patient clinical activity in a pre-doctoral, graduate, or resident program at the SOD must also follow the patient recordkeeping standards set forth in the Clinic Policy Manual. Students at all levels should complete their notes and input treatment codes by the end of their clinical session on the same day, for faculty approval. It is the student’s responsibility to obtain required faculty approval of their patient chart notes and procedure codes within the twenty-four (24) hour guideline. If a student has been monitored by an affiliate faculty member – he/she must get such notes and procedure codes approved by the end of the session.
- All SoD providers – Enforcement of Policy- Chart notes for Urgent Care Patients in 24 hours and for Routine Treatment at 7 days.
II. Training, communication and monitoring
A. Training & Communication
The SOD will reinforce training and support its providers in complying with treatment record requirements by:
- Creating and providing treatment providers with instructions on axiUm and MiPACS protocols for patient recordkeeping.
- Creating and providing hands-on training and reference materials for treatment providers on accepted practices of patient recordkeeping.
- Providing updates and/or refresher training to ensure compliance.
B. Monitoring
Monitoring will occur on two or more levels to quickly identify deficiencies and implement corrective measures before clinical processes interact with the revenue cycle process.
- “Front-line” verification to ensure that patient recordkeeping is completed and approved for processing through the revenue cycle will be conducted by:
- Clinic Floor Personnel – prior to the patient and treating provider going to the front desk and/or;
- Front Desk staff – upon check out with treating provider and/or;
- Clinic Manager – at the end of a session.
- axiUm reports will be generated on a weekly basis to ensure continual compliance and as an added layer of checks and balances with respect to:
- Lack of or missing treatment notes or procedure codes; and/or
- Unapproved procedure codes and notes; and/or
- Unacceptable standards or patient recordkeeping in axiUm (i.e. scanning or other form of recordkeeping not consistent with SoD standards)
- Timely Reporting of infractions: Report on-going deficiencies past seven (7) days but no later than fourteen (14) days to the Associate Dean for Clinics for appropriate action.
III. Enforcement
A. Warnings
To ensure that the SOD remains in overall compliance with state regulations and licensing obligations, the following corrective actions shall be employed:
- First Warning: Written communication via email and/or letter informing treatment provider and the department; suspension of clinic privileges (including faculty practice activities) if the issue is not corrected within 2 weeks from the time of the procedure. If compliance is met within timeframe, no formal record will be placed in faculty file.
- Second Warning: Elevate infraction to Associate Dean for further action if not mitigated within thirty (30) days. A permanent record of infraction noted in treatment provider’s records; disciplinary action including, but not limited to suspension of faculty practice activities, a “non-meritorious behavior” citation, and further attention regarding performance of the faculty member.
Dean of UW SOD:
Joel Berg, Dean of the UW School of Dentistry
December 21, 2015
Disney channel games sonny chance scavenger hunt. [1] Medicor Imaging Picture Archiving and Communication System – “MiPACS”
[2] See also Revised Code of Washington (“RCW”) § 18.32.655, Washington State registry (“WSR”) §§ 95-21-041 and WAC 246-817-340.
[3] See also RCW § 70.02
[4] http://www.hhs.gov/ocr/privacy/hipaa/administrative/statute/hipaastatutepdf.pdf ; accessed 05Oct2015.
axiUm is the most popular dental practice management system for dental universities in North America, with an estimated 80+% of dental institutions using the system. Though the system gets the job done, users find the interface to be dated, and the system to be a bit clunky.
Pros
- Widely used across many dental schools
- Helps students learn how to chart, and manage appointments
- Enables instructors to sign off on student work
Cons
- Dated UI
- Users find the system to be clunky
- Not popular outside of academic settings, so students will likely have to learn a new system when they begin working.
Editor's Rating Italic font free download.
3.5/5.0
Winning eleven 8 para pc completo. Used by well-known dental universities, including UCLA, NYU, Penn, Stony Brook, and many others, axiUm is the most popular dental practice management system in dental institutions across North America. The system was developed by Exan, which was acquired by Henry Schein (which also owns Dentrix and Easy Dental) in 2012. Since its acquisition, axiUm still continues to acquire new clients (both UCLA and Penn have transitioned to axiUm within the past year).
With such a strong client base, axiUm has all of the functionality required to support the needs of educational institutions. However, many users find the user interface to be dated, and clunky to use. The system comes with a bit of a learning curve, but once users familiarize themselves with the system, they tend to find it intuitive, and are able to accomplish everything that they need.
The system is Windows-based, and as you can see, has the look and feel of the Windows desktop. Each module can be accessed either through the left panel, or through the optional interactive desktop in the middle of the screen. When you open a new module, it opens a new window, which makes it easy to have multiple modules open at the same time, so that you can access all patient information quickly.
Universities typically host axiUm on their own Windows servers, and have students connect through a virtual machine, or remotely through a VPN (Virtual Private Network), which enables students to use the software on their own personal computers. This also means that students can access the system using both Windows and Mac machines, even though the system is only compatible with Windows operating systems. However due to HIPAA restrictions, some universities restrict certain information from being accessed through VPN.
axiUm has all of the basic functionality that you'd expect from a dental practice management system, including scheduling, EHR, dental charting, insurance coverage, and treatment planning. Since axiUm is primarily marketed toward universities, we'll focus the rest of our review on the academic-specific functionality that makes axiUm more appropriate for universities than traditional dental practice management systems.
Clinical Evaluations
One of the main features for academic settings is the ability for instructors to sign off on students' clinical work. When students treat patients, all of their work must be signed off by the instructor. After the instructor reviews the student's work done in clinic, they can then swipe their card through the card reader, which shows approval of the student's work, and registers the approval in the system.
Axium Download
Integration with Coursework
Axium Dental Manual 2016
Another benefit of axiUm for dental universities is that the system enables you to create courses and track student grades, as well as clinical performance. This is all integrated with the rest of the system, which prevents universities from having to use separate systems for creating coursework, and for tracking student grades.
Because they are able to access student grades and clinical performance from one system, instructors can have a cohesive understanding of how the student is performing, and can give better personalized advice for the student. The instructor can also easily identify students who are struggling. Or, if an entire class seems to be struggling with a concept, this can help instructors understand that they need to modify their coursework accordingly.
axiUm Messenger
axiUm includes a module known as axiUm Messenger, which enables users to send messages to other students and faculty. This is especially convenient when communicating information about patients, since it doesn't require any external services in order to share patient information. You can also specify the priority of messages, which are conveyed to the recipient by color. If the message is marked as high priority, the message icon in the recipient's desktop toolbar will be red -- otherwise a new unread message will result in a blue message icon.
Security
There are two main components to axiUm's security. First, the system includes an audit history for users, so that you can easily understand what changes were made, and when they were made. This is particularly helpful for instructors who are auditing student work, and who want to be able to understand a student's workflow for a particular patient. If any mistakes are made, it's easy to identify who made the changes, and revert them if necessary.
Axium Dental Support
axiUm also allows administrators to create various security profiles for different users, so that they can only access certain information. This helps limit the unnecessary spreading of sensitive information.
Conclusion
axiUm has all of the functionality you'd expect from any dental practice management system, including charting, scheduling, treatment planning, and EHR. However, the system also has many academic-specific features that make it appropriate for dental universities. Features like clinical evaluations that enable instructors to sign off on student work, as well as integrating the system with coursework, make the system more suitable for academic settings than traditional practice management systems that are designed for private practices.
Though the user interface is somewhat dated, the system is widely used across dental universities in North America, and is a safe option for any academic dental institution to consider.
To learn more about axiUm, you can visit their site here.
You can also read our interview with Michael Trieu, third-year dental student at the UCLA College of Dentistry, to learn about how he uses axiUm for his clinical work, and what he thinks about the software.