General

The CDM module initially opens to the Case > General screen where you can view/update key case information as described below.

For information on integration with AmkaiCharts and SIS Charts and workflow issues in the CDM module, see About the CDM module.

Note: If a Sheet Bar option is disabled, check the Appointment StatusAppointment Status on the Case > General screen. Click herehere to learn which Sheet Bar options are enabled with each Appointment Status.

To update the Case > General screen

1. Launch the CDM module. You will be prompted to select a patient and case. Click herehere for more information, including instructions for selecting a patient and a case. The module opens to the Case > General screenCase > General screen..
   1. When you first open the CDM module, the Person -Patient selection dialog appears, prompting you to select a patient. Click here to learn how to select a patient record.
   2. After you select a patient, the CDM Case Selection dialog CDM Case Selection dialog appears, prompting you to select a case. Highlight a case from the dialog and do one of the following:

      

   • Click View to see, but not edit case information. Or,
   • Click Edit to update/edit case information.

   Note: Only one user at a time can edit a case, but multiple users can view it at once. If you open a case someone else is already editing, a system prompt will indicate you are in View Only mode and let you know who has the case open for editing and for how long. Click the Refresh Locking Info button to see if the case has been released for editing.

    

    

   

   

2. For users of AmkaiCharts, SIS Charts, and/or SIS Advanced (available in AmkaiOffice 4.5.0 and later):
   • If case information has been imported from AmkaiCharts and SIS Charts, the data will automatically populate the appropriate fields on the General screen, and will not be editable in CDM. The case status will automatically be set to In Progress.
   • For SIS Advanced users, department times and discharge status will automatically pull to CDM and will be editable in CDM. The case status will automatically be set to In Progress.
3. The patient information sectionpatient information section at the top auto-populates from the Scheduling module. Click the links below for more information about these fields:

   

1. • PatientPatient

     To select a different patient, click the check mark icon. The Person -Patient selection dialog appears. Click here to learn how to use this dialog to select a patient.

   • CaseCase

     To select a different case, click the check mark icon. The CDM Case selection dialogCDM Case selection dialog appears. Select a case and click Edit to open the case for editing, or click View if you do not wish to edit the case.

     

   • Surgery DOSSurgery DOS

     The Surgery Date of Service defaults in from the Scheduling module. Read-only field.

   • Appointment SummaryAppointment Summary

     To view an appointment summary, click the calendar icon to the far right of patient information section (circled in red) to launch the Appointment Summary dialog. Click here to learn how to use this dialog.

     

   • RemarkRemark

     To view or create a remark, click the icon (circled below) in the far right of the patient information section. Click here to learn how to use the dialog that appears. The number to the right of the icon indicates how many remarks exist on this account.

     

4. You can update the Appointment Status and Type using the drop-down lists in these two fields. If you change either one of these items here, it also changes the item in Scheduling. The Sheet Bar options in the CDM module are enabled/disabled depending on the Appointment Status. Click herehere to learn which Sheet Bar options are available with each Appointment Status.
   • PendingPending

     Pending status means the patient has not yet been logged in as Arrived for the appointment. Available Sheet Bar options are: Case > General, PAT/Follow-up (all menu options under this heading), and Utils.

   • In ProgressIn Progress

     In Progress status means the patient has been logged in as Arrived for the appointment. Case details can be updated/edited and all Sheet Bar options are available, but the case cannot yet be billed.

   • Partially Performed/Not BillablePartially Performed/Not Billable

     If the status is Partially Performed/Not Billable, case details can be updated/edited and all Sheet Bar options are available. The case will not be billed.

   • Partially Performed/BillablePartially Performed/Billable

     If the status is Partially Performed/Billable, case details can be updated/edited and all Sheet Bar options are available. The case is billable.

   • PerformedPerformed

     If the status is Performed, case details can be updated/edited and all Sheet Bar options are available. The case is billable.

   • Direct AdmitDirect Admit

     Patient was directly admitted to the surgical hospital as a medical admit.

   • CancelledCancelled

     Appointment has been cancelled and is not billable. Available Sheet Bar options are: Case > General, PAT/Follow-up (all menu options under this heading), and Utils.

    

    

5. Click herehere to learn about the fields in the Arrival/Admission Information section.

   • Source and TypeSource and Type

     The Source (code indicating the source of the referral for the visit)  and type (code indicating the type and priority of a visit) can be set to default in the Preferences dictionary. You can change these codes here by typing in the free text fields.

     Note: this information is used in claims processing and in many state mandated reports

   • ArrivalArrival

     Arrival date/time default in from the Scheduling module once completed at the front desk.

   • AdmissionAdmission

     Admission time defaults in from AmkaiCharts. If you do not use AmkaiCharts, you can enter the Admission time in this field.

   • Admitted byAdmitted by

     Select the name of the physician who admitted the patient from the drop-down list.

6. Click herehere to learn about the fields in the Discharge Information section.

   • Date and TimeDate and Time

     Enter the Discharge Date and Time on this screen. This information can also be entered on the Case > Times screen in the Department Time Log. The information will then auto-fill into the Date and Time fields in the Discharge Information section.

   • StatusStatus

     Select a discharge status from the drop down menu. If you do not find the appropriate status, use Alt + e or Alt + d to jump to the dictionary.

   • Discharged byDischarged by

     Select the appropriate provider from the drop down menu.

   • CommentsComments

     Enter any comments in the free text field.

   Click the check mark icon to attach a document to the patient's record. Click here to learn how.

    

    

7. Click the Preference Card button to load information from the Preference Card into the CDM module. After you click this button, the Procedure Description on the Card populates the Description field, and any Supplies/Resources noted on the Card will populate in the Supplies/Resources/Trays section, which you can edit/update by clicking the Supplies/Resources Sheet Bar option under the Case heading.
8. The Pre-Admit Ques/Instructions Given field can be updated manually or automatically by SIS Advanced or by AmkaiCharts or SIS Charts. If a case is canceled after questionnaires have been attached, the fields in CDM will be cleared. The document still can be accessed in the Document Central module.

   • For facilities that use SIS Advanced, when a Pre-Admit Questionnaire has been received or manually completed by the staff in SIS Advanced, the system will automatically import a copy of the questionnaire into the CDM module as a PDF document. In the Pre-Admit Ques/Instruction Given section, all three icons will become active: the check mark, printer, and minus sign. The automatic document import will not automatically fill the Yes check box, Date, or user. If you would like the fields completed, you must enter/select the data manually. You can also manually scan or attach documents using the check mark icon after manually updating the case to In Progress.  

   • To manually document any Pre-Admit Questions/Instructions given to the patient, update the case status to In Progress and click the Yes check box. The Date field will populate with today's date. Use the drop-down arrow to change it if needed. Use the drop-down list in the By field to select the name of the person who gave the instructions to the patient. Click the check mark icon to attach a copy of the instructions given. Click here to learn how.  

9. In the H & P on File section, click the Yes check box to indicate whether your facility has H & P (history and physical) on file for this patient. The date will auto-populate as today's date, but you can select a different date from the drop-down list. Select the name of staff/physician who accepts responsibility for the H & P from the drop-down list. Click the check mark icon to attach a document to the patient's record. Click here to learn how.
10. The Post-Op Ques/Instructions Given field can be updated manually or automatically, either by SIS Advanced or by AmkaiCharts or SIS Charts. If a case is canceled after questionnaires have been attached, the fields in CDM will be cleared. The document still can be accessed in the Document Central module.

    • For facilities that use SIS Advanced, when a Post-Op Questionnaire has been received or manually completed by the staff in SIS Advanced, the system will automatically import a copy of the questionnaire into the CDM module as a PDF document. In the Post-Op Ques/Instruction Given section, all three icons will become active: the check mark, printer, and minus sign. The automatic document import will not automatically fill the Yes check box, Date, or user. If you would like the fields completed, you must enter/select the data manually. You can also manually scan or attach documents using the check mark icon after manually updating the case to In Progress.  

    • To manually document any Post-Op Questions/Instructions given to the patient, click the Yes check box. The Date field will populate with today's date. Use the drop-down arrow to change it, if needed. Use the drop-down list in the By field to select the name of the person who gave the instructions to the patient. Click the check mark icon to attach a copy of the instructions given. Click here to learn how.  

11. The fields in the Physicians section default with the names of the doctors assigned in the Scheduling module. To change any of these physicians, use the drop-down lists.
12. Click here to learn how to update the Implant/Prosthetic Log.
13. Click here to learn how to update the Pathology/Specimen Log.
14. Click Save to save your changes to the CDM module. If you are finished updating the CDM module for the current patient, click Save & Next to save your changes and search for the next patient record.

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