CQM - record CMS69v10 (MU3)

Encounter Performed

• example record entry for Encounter Performed

Medication Order

• example record entry for Medication Order

Intervention Order

• In the Care Plan form add an entry with Intervention for Type
• Search for the appropriate code from the code popup
• Select the date
• Enter the attributed reason code for the order. 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

Intervention Performed

Create/Find procedure order

• Use the Administrative->Procedure Order Form
• Enter the Time Collected and select Intervention from the Default Procedure Type drop-down
• Search for the appropriate code from the Procedure Test find code popup, usually found in the CQM value set.
• Enter the attributed reason code for the test if there is one by clicking the asterix and use the find code popup to search for the code from the value set. 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

Physical Exam Performed

Create/Find Observation form

• Create an observation form under Clinical->Observation

Physical Exam Type

• In an Observation form choose Physical Exam Performed for Type
• Search for the appropriate code from the code popup for the exam
• Enter the appropriate value for the result, like for BMI a value of 30
• 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