OpenEMR USER MANUAL

Copyright (c) 2005 Open Source Medical Software

Permission is granted to copy, distribute and/or modify this document under the terms of the GNU Free Documentation License, Version 1.2 or any later version published by the Free Software Foundation; with no Invariant Sections, no Front-Cover Texts, and no Back-Cover Texts.
A copy of the license is included in the section entitled "GNU Free Documentation License".

Please note that this manual is intended to be a starting point for those trying to use the program and as OpenEMR improves, this manual will be updated to reflect those changes. Do not assume, however, that the instructions contained in this manual apply to the most recent development version. Notification of any errors or omissions should be e-mailed to emilykillian@charter.net

 

NAVIGATION INDEX

Getting Started

Patient Demographics

Appointment Scheduling

Patient Encounters

Patient Medical Data

Billing, Insurance, Payments
and Accounts Receivable

Reporting

Prescriptions

Authorized Users

Transactions

Image Gallery

Future Changes to the Manual

GNU FDL

 

 

GETTING STARTED

Logging in

The main login screen should be the first screen to come up in the Internet browser. That screen will have a box with a pull down menu labeled group.
Choose the correct group from that pull down list.
Below the group, there should be an input box labeled user name, where the user should type his or her user name. The box below it should be called password and the user should type his or her password there.
Once the correct group, user name and password are entered, click on the login button.
If the system does not log the user on the first time, check to make sure the user name and password are typed in correctly and that Caps Lock was not on.

Please click on the following thumbnail for a detailed picture.

Changing passwords

To change a user password, that user should log in using their old password.
Once logged in, the user should click on change password in the top rail.
Then type in the new password in the input boxes.
Click on save changes.

Please click on the following thumbnail for a more detailed picture.

Getting back to the main screen

To get back to the main screen, click on home from the top rail.
If there is not a link for home, there should be a link for back.
Click back to get to the main screen.
If there is not a link for back, click on close, which is also located in the top rail.

Please click on the following thumbnail for a more detailed picture.

Return to Navigation Index

PATIENT DEMOGRAPHICS

Searching for a patient

To search for a patient, go to the top, left corner and type the patient's last name, ID number, social security number or date of birth into the input box.
Select the criteria type from the pull down box beside the input box and click patient demographics.

Entering patient demographics for new patients

To enter patient demographics for a new patient, go to the top, left-hand corner of the screen and select new patient.
Type the rest of the patient's personal information like last name, social security number, address, phone, employer and date of birth.
Click on save demographics.

Please click on the following thumbnail for a more detailed picture.

Entering patient insurance

Once you have entered patient demographics and saved them, begin entering in insurance information. There is space for at least three insurances per patient.
Either choose an established insurance type from the drop down list or create your own.
If using the drop down list, continue filling in the insurance blanks and click save patient demographics. Do the same for secondary and tertiary insurance whenever applicable.
If creating a new insurance, click on add new insurer.
Fill in the blanks, choose the correct payer type and hit update.
Click on close in the top right-hand corner of the page.
Go back into the patient's account and select the insurance, which has been added to the drop down list.
Click save patient demographics and review the patient's information to make sure it is correct.

Adding or modifying patient demographics

Once in the patient's health record, click on the demographics link near the top, left-hand side of the page.
Begin filling in the blanks that apply to your patient and click on save demographics.

Editing a patient's demographic information from the appointment scheduler

Each patient appointment has a colored box with appointment and patient information displayed. They also have a button with a folder logo.
Clicking that button will bring up the patient's demographic information, which can be edited from there.

Return to Navigation Index

APPOINTMENT SCHEDULING

Searching for an appointment

From the main screen, click on search.
Type in your keyword, which can be the patient's last name or a word in the appointment description.
To view the appointment from there, click on the patient's name or the appointment description. Both will be highlighted in blue.

Adding an appointment

To add an appointment from the main screen, type in the patient's last name, date of birth, social security number or identification number in the input box at the bottom-left of the screen.
Choose from the drop down menu the search criteria you are looking under.
Click on search.
A list of possible matches will be displayed to the right of the input box. Select the patient match you want to view by clicking on it.
Under event title, type in the type of appointment (established patient follow up, new patient visit, etc...).
Select the appointment date, provider, appointment category, time and duration.
Then hit go.
A message that says your event has been submitted will appear.

Please click on the following thumbnails for more detailed pictures.

     

Adding an appointment from the calendar

Click on the + sign beside the time chosen for the appointment.
Fill in the appointment details and the patient's name and provider and click go.
A message stating the event has been submitted should be visible at the top of the screen.

Please click on the following thumbnail for a more detailed picture.

Editing an appointment that has already been made

From the main screen, enter the patient's last name, identification number, social security number or date of birth in the input box located at the top of the screen.
Select the criteria you chose for the search and click on find. This will bring up the patient summary screen.
Click on the appointment type.
Click edit, then make your changes and click go.
If the appointment is already displayed on the main screen, click on the appointment description and go through the above process.
Once you have clicked go, a note should appear at the top of the screen that says the appointment has been modified.

To view only one practitioner's schedule at a time

To view only one practitioner's schedule, click on that practitioner's name from the drop down list and click jump.

Moving from one calendar view to another (day, week, month or year)

From the main screen, click on the view you would like to see. This can either be day, week, month or year and is located at the right-hand side of the page.

Double booking

Book the appointment like normal. The program will pop up an alert message about double booking.
Click go a second time to approve the double booked appointment.
This only works correctly if it is a new appointment instead of a rescheduled one.
The words double booked should appear on the appointment.

Please click on the following thumbnail for a more detailed picture.

Blocking out time for providers' days and times off

Enter the time like a regular appointment and edit it like a regular appointment.
The only exception is when a patient's name would normally be selected from the drop down menu, click on none specified.

Deleting scheduled appointments

Click on the appointment description.
Click on delete.
At the top of the page, click on yes to delete the appointment.
Click jump to return to the appointment scheduler.

Printing schedules

From the main screen, click on the date you want to print.
This will bring up a list of appointments.
Click print at the bottom right-hand corner of the schedule box.
This will bring up a single-page list.
Print like a normal Internet document. Close the list's window.

Return to Navigation Index

PATIENT ENCOUNTERS

Entering a new encounter from the appointment scheduler

From the main screen, patient appointments are listed in boxes. Each scheduled appointment has a button that looks like an arrow that is pointing downward.
Clicking that button will take you to the new patient encounter form, where the patient's reason for being seen can be entered in the input box.
Once that is typed, click to save.

Please click on the following thumbnails for more detailed pictures.

     

Entering a new encounter from the patient's summary screen

Click on encounter located at the top of the page.
Click on new patient encounter and type the patient's reason for being seen in the input box.
Once that is typed, click save.

Please click on the following thumbnail for a more detailed picture.

Entering vital signs

Once the new patient encounter form is finished, click on vital signs from the menu on the right rail.
Type in the patient's vital signs in the appropriate input boxes and click save.

Please click on the following thumbnail for a more detailed picture.

Entering additional patient notes

For patient phone calls and refills, bring up the patient's summary page.
Click on patient notes, located on the right rail, and enter the note in the input box.
Click add new note.
To view only active or inactive notes, click on your viewing preference under the input box.

Return to Navigation Index

PATIENT MEDICAL DATA

Updating medical problems list

Click on medical problems along the bottom rail.
To add a problem, click in the top input box.
Extra notes can be added in the bottom input box.
Click on add new medical problem.
When finished, click back or close.

Please click on the following thumbnail for a more detailed picture.

Updating medications list

Click on medications along the bottom rail.
To add a medication, click in the top input box.
The medication name should go in the top box and additional information should go in the bottom box.
Click on add new medication to save.
When finished, click back or close.

Please click on the following thumbnail for a more detailed picture.

Updating allergies list

Click on allergies along the bottom rail.
To add an allergy, click in the top input box. Extra notes can be added in the bottom input box.
Click on add new allergy.
When finished, click back or close.

Please click on the following thumbnail for a more detailed picture.

Updating surgeries list

Click on surgeries along the bottom rail.
To add a surgery, click in the top input box.
Extra notes can be added in the bottom input box.
Click on add new surgery.
When finished, click back or close.

Please click on the following thumbnail for a more detailed picture.

Updating immunizations list

Click on immunizations along the bottom rail.
To add an immunization, click in the top input box. Extra notes can be added in the bottom input box.
Click on add new immunization.
When finished, click back or close.

Please click on the following thumbnail for a more detailed picture.

Return to Navigation Index

BILLING, INSURANCE, PAYMENTS AND ACCOUNTS RECEIVABLE

Adding a CPT code

To add a CPT code, click on superbill at the bottom of the screen.
Fill in the blanks by choosing the type of code to add and by typing in the numerical code.
Modifiers may need to be used for certain CPT codes.
Enter the number of units or days, which typically is only one. Hospital visits and lesion destructions often have more days/units.
Enter the fee charged for the service and from the next drop down menu, choose to include the code on the superbill.
Click on add code.

Please click on the following thumbnail for a more detailed picture.

Deleting an ICD-9 code from a patient's encounter

After an ICD-9 code has been entered and it's unwanted, click on the code under the billing column.
Then click delete to eliminate it.
Please note that this will not permanently delete the code from the main list.

Entering copays

Copays can be entered by clicking on copay in the bottom left rail.
In the copay column, type in the patient's copay and click save.
The copay amount will move automatically to the superbill column.

Please click on the following thumbnail for a more detailed picture.

Entering charges

Entering charges can be done by clicking on superbill in the left column.
If it does not already appear in the column, click on more and add the CPT code (covered under Adding a CPT code).
If the code appears on the list, click on the code you wish to charge.
Add any necessary modifiers and the number of units or days for each procedure. The service's fee should already be entered.
Choose to include the charge on the superbill.

Please click on the following thumbnail for a more detailed picture.

Deleting a CPT code that has been entered in the charges

An unwanted CPT code can be deleted from the charges by clicking on it under the billing column.
Click delete and then click on billing to go back to the previous screen.

Return to Navigation Index

REPORTING

Creating reports

From the patient's summary screen, click on report at the top rail.
Choose the patient information that should be included by checking the boxes beside desired information.
After making selections, click on generate report.

Please click on the following thumbnails for more detailed pictures.

     

Printing reports

After generating a report, click on printable version.
Print the document and close the print window.

Work and school notes

To create a work or school note that relates to a specific visit, go into the patient's account and click on encounter.
Choose the correct date of service from the list and under the new form column, choose work/school note.
From the drop down menu, choose whether it will be a work or school note.
Personalized messages about the patient's absence can be added in the input box for messages.
Choose the correct provider from the drop down list and hit save.
Once the note has been saved, click on printable view and print the note.
Make sure to send the document to the correct printer.

Return to Navigation Index

PRESCRIPTIONS

Writing prescriptions

From the patient's encounter screen, choose an encounter by clicking on it.
On the left rail, click on add prescription.
Fill in the date the patient should start taking the medication, provider, drug name, quantity, units, directions and refills.
Once the prescription is finished, click on prescribe.
Then print, e-mail, fax or auto send the prescription to the selected pharmacy.

Please click on the following thumbnails for more detailed pictures.

     

Printing and sending prescriptions

After adding the prescription information, click on prescribe. Then either click print, e-mail or fax.
To e-mail or fax, type in the number or address and click on the method that should be used to send the prescription.
To automatically send the prescription via the pharmacy's preferred method, click auto send.

Looking up medications

Click on drug lookup. The program will pop up a dialog box.
Type the name of the medication in the box and click search. The box will bring up a list of possible matches.
Choose the medication from the list and click select. The box will close automatically and the drug name will appear on the prescription.

Please click on the following thumbnail for a more detailed picture.

Adding pharmacies

From the patient's summary screen, click on demographics.
Then click on add new insurer under any of the insurance categories.
Click on add a pharmacy.
Fill out the pharmacy name, address, e-mail and phone and fax numbers.
Choose the default method that should be used to send prescriptions to this pharmacy.
Click update.
To auto send, click on the correct pharmacy from the drop down menu.
An administrator can also add pharmacies by clicking on administration and then practice settings.
Click on add a pharmacy and complete the input boxes.
Click update, then click on pharmacies to check.

Please click on the following thumbnail for a more detailed picture.

Changing pharmacy information

From a patient's summary page, click on demographics.
Click on add new insurer from any of the insurance categories.
Click on pharmacies. Click on the name of the pharmacy and click update.
This can also be done through administration.

Please click on the following thumbnail for a more detailed picture.

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AUTHORIZED USERS

Authorized users can perform additional functions to which normal users do not have access. These include approving office notes and billing. A provider's main screen will include his or her schedule of appointments and billing and office notes that need to be authorized. Authorized users also have access to administrative tasks, along with practice and calendar settings and forms.

Authorizing office visits and notes

On the bottom rail, click authorize, which is located underneath the patient's name. This will clear the name and the transactions from the rail.

Please click on the following thumbnail for a more detailed picture.

Generating reports

Authorized users can generate reports on race, no shows, appointments and codes, among others.
To generate a report, choose the report type and the variables, then choose how many results to show and click go.

Add a new user

Click on administration at the top rail. Fill in the new user information and click on add user.

Please click on the following thumbnail for a more detailed picture.

Add new groups

Click on administration at the top rail.
Fill in the new group information and click on add group.

Please click on the following thumbnail for a more detailed picture.

Add new facilities

Click on administration at the top rail.
Fill in the new facility information and click on add facility.

Please click on the following thumbnail for a more detailed picture.

Printing schedules

From the provider's main screen, click on print, which is located at the bottom, right-hand corner of the practitioner's schedule. This will bring up a printable page.
Print the page like a normal document.

Adding an appointment category

Click on administration and then on calendar settings.
Click on categories.
Scroll down the list that comes up to make sure the category you want to add is not already on the list.
If not, then scroll back up to the top of the list and begin entering in the category title.
Click on pick to bring up a box with colors you can select for the background.
Select a color that has not been chosen before.
You may enter in a description of the category.
Click commit changes and then click yes to confirm.

Please click on the following thumbnail for a more detailed picture.

Return to Navigation Index

TRANSACTIONS

Entering a referral or forms information

After filling out a form for a patient or making a referral appointment, from his or her summary screen, click on transaction.
Choose the type of transaction from the drop down menu.
Type details about the form and what we filled out in the input box.
Then click on add new transaction.

Please click on the following thumbnail for a more detailed picture.

Return to Navigation Index

IMAGE GALLERY

Click on the gallery images below to bring up larger screen shots

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GNU FREE DOCUMENTATION LICENSE


www.fsf.org
Version 1.2, November 2002
Copyright (C) 2000,2001,2002 Free Software Foundation, Inc.
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If the Cover Text requirement of section 3 is applicable to these copies of the Document, then if the Document is less than one half of the entire aggregate, the Document's Cover Texts may be placed on covers that bracket the Document within the aggregate, or the electronic equivalent of covers if the Document is in electronic form. Otherwise they must appear on printed covers that bracket the whole aggregate.

8. TRANSLATION
Translation is considered a kind of modification, so you may distribute translations of the Document under the terms of section 4. Replacing Invariant Sections with translations requires special permission from their copyright holders, but you may include translations of some or all Invariant Sections in addition to the original versions of these Invariant Sections. You may include a translation of this License, and all the license notices in the Document, and any Warranty Disclaimers, provided that you also include the original English version of this License and the original versions of those notices and disclaimers. In case of a disagreement between the translation and the original version of this License or a notice or disclaimer, the original version will prevail.
If a section in the Document is Entitled "Acknowledgements", "Dedications", or "History", the requirement (section 4) to Preserve its Title (section 1) will typically require changing the actual title.

9. TERMINATION
You may not copy, modify, sublicense, or distribute the Document except as expressly provided for under this License. Any other attempt to copy, modify, sublicense or distribute the Document is void, and will automatically terminate your rights under this License. However, parties who have received copies, or rights, from you under this License will not have their licenses terminated so long as such parties remain in full compliance.

10. FUTURE REVISIONS OF THIS LICENSE
The Free Software Foundation may publish new, revised versions of the GNU Free Documentation License from time to time. Such new versions will be similar in spirit to the present version, but may differ in detail to address new problems or concerns. See http://www.gnu.org/copyleft/.
Each version of the License is given a distinguishing version number. If the Document specifies that a particular numbered version of this License "or any later version" applies to it, you have the option of following the terms and conditions either of that specified version or of any later version that has been published (not as a draft) by the Free Software Foundation. If the Document does not specify a version number of this License, you may choose any version ever published (not as a draft) by the Free Software Foundation.

ADDENDUM: How to use this License for your documents
To use this License in a document you have written, include a copy of the License in the document and put the following copyright and license notices just after the title page:
Copyright (c) YEAR Organization.
Permission is granted to copy, distribute and/or modify this document under the terms of the GNU Free Documentation License, Version 1.2 or any later version published by the Free Software Foundation;with no Invariant Sections, no Front-Cover Texts, and no Back-Cover Texts.
A copy of the license is included in the section entitled "GNU Free Documentation License".
If you have Invariant Sections, Front-Cover Texts and Back-Cover Texts, replace the "with...Texts." line with this:with the Invariant Sections being LIST THEIR TITLES, with the Front-Cover Texts being LIST, and with the Back-Cover Texts being LIST.
If you have Invariant Sections without Cover Texts, or some other combination of the three, merge those two alternatives to suit the situation.
If your document contains nontrivial examples of program code, we recommend releasing these examples in parallel under your choice of free software license, such as the GNU General Public License, to permit their use in free software.

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