CQM - record CMS69v10 (MU3)

Encounter Performed

Find/Create encounter

• Use past encounters or create a new encounter
• Under Visit Details select the appropriate option from the Type Drop-down that corresponds to the code in Lists->Encounter Types.

Create/Find Care Plan form

• Create a care plan under Clinical->Care Plan

Medication Order

• In the Care Plan form add an entry with Planned Medication Act for Type
• Search for the appropriate code from the code popup
• Select the date
• If this an exception case click the asterix to choose the Negated reason and enter the appropriate code from the look up.
• Save the form

Create/Find procedure order

• Create a procedure order under Admin->Procedure Order

Intervention Order/Performed

• Use the Administrative->Procedure Order Form
• Choose Intervention from the Default Procedure Type
• Search for the appropriate code from the Procedure Test find code popup
• Enter the Reason Code for the test by clicking the asterix and use the find code popup to search for the code from the value set and choose pending or completed for the reason status. Otherwise if this an exception case choose negated and enter the appropriate code from the look up.
• Save the order

Create/Find Observation form

• Create an observation form under Clinical->Observation

Physical Exam Performed

• In an Observation form choose Physical Exam Performed for Type
• Search for the appropriate code from the code popup
• Select the date
• If this an exception case click the asterix to choose the Negated reason and enter the appropriate code from the look up.
• Save the form

Diagnosis

• Add a medical problem with the appropriate code and set the begin date and end date if valid and select Diagnosis as the Classification Type