Templates for Patient Documents

Overview

This feature is new as of OpenEMR release 4.1.3 (March 2014). It provides the ability to upload Templates in an Open Document format (MS Word or OpenOffice or LibreOffice), or as plain text or perhaps for other formats. Use them as boilerplate for creating documents that can then be uploaded to the patient documents area in the usual way or downloaded to the "Local" computer.

• {PatientName} (FirstName Middle Lastname)
• {PatientID} (External ID)
• {PatientDOB} (yyy-mm-dd)
• {DOS} (Date of service in the format of yyyy-mm-dd)
• {ReferringDOC}(Name of refferer doctor)
• {ChiefComplaint}
• {Allergies}
• {ProblemList}
• {PatientSex}
• {Address} (street address only i.e. 1224 Oakdale Rd.)
• {City}
• {State}
• {Zip}
• {PatientPhone} (output in this form: (000)000-0000)

Installing a Template

The first step is to create a Template on your local computer with one of the mentioned word processors.

The to be Uploaded Templates may contain any of these keywords (the fields {...} contain the information entered during Demographics, and other history or summary during the encounter)

Next step is to upload the Template made with the mentioned {.. fields ..} and give the Template a well recognizable name.

Browse => Give the Template the correct name =>

Use the same menu options as before: Template uploading is done via a new menu item, Miscellaneous => Document Templates (and so becomes a generals usable Template).

Using a Template

In the documents area, a drop-list has been added where you may select and download a document.

To create a document for a certain Client, be sure to enter some information that will show as an encounter.

The Template always has to be connected to Client information.

Go to Client => Summary => Documents => Patient Information => Search in the line for: Download document-template for this patient and visit. Select Template => Fetch => Make a choice to "Open with" or "Save file" .......

The downloaded document will have its keywords replaced with actual data from the currently selected patient and encounter.

There you are: The file will be opened in your favorite Word processor and is ready for some additional corrections, formatting, do final edits, or save it (perhaps as a PDF). Next the file can be send as e-mail attachment, printed, or saved for later use or upload the finalized file as a patient document in the usual way.

Template with all available {fields}:

Copy => Paste the text between the Horizontal lines and past in you Word Processor and Upload as suggested in text.

---

HIPAA Declaration

The Practice: (a) Is required by federal law to maintain the privacy of your PHI and to provide you with this Privacy Notice detailing the Practice's legal duties and privacy practices with respect to your PHI (b) Under the Privacy Rule, it may be required by State law to grant greater access or maintain greater restrictions on the use or release of your PHI than that which is provided for under federal law (c) Is required to abide by the terms of the Privacy Notice (d) Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all of your PHI that it maintains (e) Will distribute any revised Privacy Notice to you prior to implementation (f) Will not retaliate against you for filing a complaint

Patient Communications: Health Insurance Privacy Act 1996 requires we inform you of the following government stipulations in order for us to contact you with educational and promotional items in the future via email, U.S. mail, telephone, and/or pre- recorded messages. We WILL NOT ever share, sell, or “SPAM” your personal contact information. Marketing any communication about a product or service that encourages recipients to purchase or use the product or service. Communication can be defined as Voice Blasts, Email, and numerous marketing pieces. Communications to describe health-related products or services, or payment for them, provided by or included in a benefit plan of the covered entity making the communication.

(a) Communications about participating providers in a provider or health plan network, replacement of or enhancements to a health plan, and health-related products or services available only to a health plan’s enrollees that add value to, but are not part of, the benefit plan.

(b) Communication for treatment of the individual

(c) Communications for case management or care coordination for the individual, or to direct or recommend alternative treatments, therapies, healthcare providers, or care settings to individuals PATIENT ACKNOWLEDGEMENT

I acknowledge receipt of this notice, and my understanding and my agreement to its terms.

Patient Name: {PatientName} (FirstName Lastname); {PatientSex} (in characters) {PatientID} ( External ID); Born: {PatientDOB} (yyy-mm-dd) Home Address: {Address} (Example: street address only i.e. 1224 Oakdale Rd.) Zip: {Zip}; City: {City}; State: {State} Home Phone: {PatientPhone} (output in this form: (000)000-0000)

{PatientName} Witnessed by: {ReferringDOC} Patient Signature: Witness Signature:

_________________________ _________________________

Date: {DOS} (Date of service)

For Internal Use:

Patient Refused to Sign: _____________________ Patient unable to sign for the following reason: _______________________________

I declare that today I have the following complaints: {ChiefComplaint}

I have suffered in the past and might still be suffering from: {Allergies}

I am aware that I have, have had the following Medical complaints: {ProblemList}

---

Problems

One gotcha is that the Word Processing Application might insert XML tags randomly into the middle of keywords as you type them in (This happens when using a non-plain text word processor) It keeps the parser fields from being recognized as keywords at download time.

Advise: keep a list of the Parser Fields as plain text in another plain text file and Copy => Paste to insert them into the document.