AxiUm Training - School of Dentistry

LSU Health Sciences Center School of Dentistry
AxiUm Training
Faculty
Kathy Hansel
2012
AxiUm Training for Faculty
Kathy Hansel, Instructor [email protected] room 2305 Clinic Building
504.941.8139
How to Use This Manual:
1. View Training Videos on LSUSD website.
AxiUm Tutorials- LSUSD website - http://www.lsusd.lsuhsc.edu/- Quick Links- axiUm Training- Training videos
Introduction to Axium Tutorial , Faculty Grading & Approval & EHR Demo Video- recommended viewing
a. Review this manual so that you know where the information is when you need it.
2. Complete the Training Exercise at the end of this manual.
3. Schedule a training session with Kathy Hansel so that you can be assigned an approval code.
When assigned a permanent approval code, safeguard it- it is your signature in an electronic chart. If you feel it
has been compromised at any time, see Kathy Hansel to change it.
Log onto any clinic laptop using your LSU username and password.
Click on the AxiUm icon & enter your approval code (; -4 characters-enter) to open axium in your name.
Access to AxiUm
page 3
Start Checks
4-5
Electronic Health Record EHR module (charting) 6-7
Faculty Approvals
Grading
8
9-10
Adding/ Editing Grade Forms
11
Selecting a patient (Rolodex)
Writing Notes
Charting Findings
12
13
14
Treatment Planning Module cheat sheet
15
Adding Planned treatment (not on initial TP)
Completing & Approving Tx
Finding Forms (consults)
Perio Charting
16
17
18
19
****Faculty Step-by-Step Cheat Sheet for Clinic
Indications for Medical Consult
21
Adult Medical History 22-23
****Training Exercise for Faculty 24-32
20
Remote Access to AxiUm:
Off Campus
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Go to LSUSD Home Page http://www.lsusd.lsuhsc.edu/
Quick Links drop down at top of page
Select Citrix - Use LSU username and password
Select Applications tab when Citrix Online Plug-In window appears, you should see Axium iconlog on using axium logon and password
To access Schick (CDR Dicom), you will have to open remote desktop connection through citrix
Hit Start button – lower left corner of Citrix window
Select Remote Desktop Connection (computer name : lsusd-terminal. lsuhsc.edu)
Connect
Use LSU username and password
Hit Start button in this window to find CDR Dicom (Schick radiographs) program.
Axium is installed on clinic and library computers only.
On Campus
1. Go to LSUSD Home Page
2. Quick Links drop down at top of page
3. Select Axium Training
4. Select On- Campus Axium Access
5. Use LSU username and password in Windows Server window
6. Double click on Axium icon- use axium username and password or your approval code in username field
7. Hit Start button in this window to find CDR Dicom (Schick radiographs) program.
Remote desktop download for macs:
http://www.microsoft.com/download/en/details.aspx?id=18140
Link to Citrix for macs:
https://citrixweb.lsuhsc.edu/Citrix/XenAppJava/auth/login.aspx
Kathy Hansel Axium Administrator
Room 2305
[email protected]
504.941.8139
3
FACULTY START CHECK
THE AXIUM Faculty Start-check process requires student providers to get a “start
check” from a faculty member before proceeding with an appointment.
Appointment must first be entered into student’s schedule.
In lower left corner of axium screen:
Red provider name indicates that a start check is required and is awaiting approval.
Green indicates that a start check was required and it has been approved.
Yellow indicates that a start check is required for an upcoming appointment that requires
approval.
Start-Check Dialog
The instructor left clicks on the red name field and the Appointment Start-Check Dialog
is displayed. Treatments that have been approved to be performed at today’s
appointment will be displayed on the right side of the window.
Highlight procedures from Planned Treatments window to be completed today by
student and hit > button to move to Approved Treatments window- enter approval
code to close window. Provider name light turns green.
Hitting the View button in this window opens a Crystal report that outlines today’s
treatments and the future planned treatments.
4
Text will appear RED for those procedures that have been approved in the start
check in the In Progress tab.
A symbol appears next to procedures approved in the start check in the Tx
History tab.
If other procedures are added for this appointment, the text will appear BLUE
and the “Treatments have not been start checked” warning window will appear
when the approve/ edit window appears.
If you wish to continue, just hit enter.
Start-Checks and consecutive appointments
At 30 minutes before (or less in case of a short notice appointment) the provider's next
appointment begins a Start-Check. The provider name field background color will
change from green (the color indicating a start check for the current appointment was
performed) to yellow. Yellow indicates that the next appointment will require a start
check but that the current appointment is ongoing and a start check may not be possible
to perform immediately.
A Start-Check can be performed at any time the field is red or yellow.
When the current appointment is over the provider name field background color will
change from yellow to red if a Start-Check is still required for the next appointment.
5
EHR Module- Tx History tab
1- Probing depths- last exam
2- Medical alerts- same as red alert button in status bar, automatically updates from medical
history
3- Current medications automatically updates from medical history
4- Odontogram
5- Planned treatment- yellow dots in odontogram, red text at bottom of Tx history tab, P in status
column
6- Tx History tab
7- Existing restorations/conditions, caries- Findings from initial exam, pink text
8- Completed treatment, approved black text, C in status column
9- Click on date column heading to sort entries by date (click on Site heading to sort by tooth #)
10- Click on up arrow to open bottom half of window to full screen
Blue text- unapproved treatment, notes, forms
Blue chart number button in status bar- approval needed, click on button to view unapproved items
6
axiUm charting symbols for
odontogram
EHR Module
7
Faculty Approvals
Forms (caries risk assessment, denture diagnosis from, exit exam form, etc.)
Click on
(chart # box, at bottom of screen). Click on
at bottom of Patient Approvals window.
The form requiring approval will open in a new window for you to review. Hit
button. Enter your approval
code bringing up a Form Approval window. If the student completed more than one form, select All Pages. Enter
approval code. (semicolon; - 4 character code- Enter)
Approve button will grey out and your name will appear next to it.
Findings, Planned and Edited Tx
(chart # box, at bottom of screen). You can approve all the items listed at once or you can highlight
Click on
the items you wish to approve and enter your approval code. (semicolon; - 4 character code- Enter)
Chart # box will turn grey when complete.
Notes
Students should add a note for each visit. The note will pop up for approving when approving any itens above or by
itself. The note can be edited before approving. Enter approval code. (semicolon; - 4 character code- Enter)
Chart # box will turn grey when complete.
Tx Plan
,
,
,
,. Faculty will review Tx Plan and enter approval code.
Click on
(semicolon; - 4 character code- Enter) Click on Close. The student should now get patient approval.
Perio
Click on
tab or Perio Chart module
, and click on
to resume entry on your chart. Click on
Complete. Enter approval code. (semicolon; - 4 character code- Enter) Close Perio.
See separate sheet for Completing and Approving Treatment.
Kathy Hansel
Axium Support
504.941.8139
Room 2305
03/11
8
Grading for Faculty
Planned treatment status should be changed from Planned to In Process or Complete.
(
or
, tab, double click on Tx procedure and change to I or C)
Click on
(chart # box, at bottom of screen).
Enter approval code (semicolon; - 4 character code- Enter) to approve treatment/ notes.
Grading card will appear. Enter Discipline for juniors or sophomores and proper grade form will appear.
(For seniors, use SS- Fourth Year Summative Grade form for all procedures.)
Procedure code and questions should appear in lower half of screen.
Select a question and then double click on desired grade or type in grade for each question.
Enter approval code (semicolon; - 4 character code- Enter) when finished.
To view other grade forms for this procedure, click on View Other button at bottom right of grade card,
All instructors- Search- select form from list- View:
9
For the 3-2-1 grading scheme, a grade of a 1 or a 3 requires a comment. Type in comment and hit OK to close
comment window.
If answers are required for some questions, the text will turn red when attempting to approve.
Go back and add grades for those questions.
Enter approval code.
Chart # box will turn grey when complete.
If not, hit aqua chart # button and see what needs approval; it may be forms at bottom of approval window.
Kathy Hansel
Axium Support
504.941.8139
Room 2305
07/10
10
Adding or Editing Grade Forms
To change/edit a grade on a grade form:
To Add a grade for treatment that was approved but not graded:
Open patient’s chart in Rolodex
Go to EHRtabRight click on completed and approved procedure and select – Add Student eval
Faculty must enter approval code to access grade form.
To approve and grade treatment:
Open patient record in Rolodex
Hit aqua chart number button at bottom of screen…Faculty must enter approval code
Grade form will appear- select discipline – then select grade form- add grades – enter approval code.
Students: to view all grade forms- go to Evaluations moduleEvaluations tab- set date range- Search- view grade forms
Grades tab- set date range- Search- view list of individual grades
Kathy Hansel
504-941-8139
08/2012
11
Selecting a Patient Via the Rolodex
1. Click on Rolodex button.
2. In name field, type in the last name, (and as little of the first name as is necessary to pull up a reasonable
list of names) You can also search by chart #, phone number (omit area code), birthdate, and first name (,Mary). If you fail to
adequately narrow down your search (eg. Smith) you significantly increase search time and number of names to scroll through.
3. Click on the patient’s name.
4. Make sure that the patient’s name displays in the bottom name field.
5. Check the patient’s demographic data to insure you’ve selected the correct record and that the data is current Corrections should be made by the Business Office.
6. To hold the name in your notepad for easy selection on another day, check the box on the left If the patient’s
name is in the notepad, a single click will select the patient.
Revised 06/12
12
Adding Notes to Tx History Window
AxiUm offers two methods for adding notes to the Tx History window: Tx Notes & General Notes.
Tx Notes — Should be used in virtually all cases —
How
1. Highlight the tx code
2. Right mouse click, select Add Tx Note
When
• On first visits or visits with no single tooth treatment, attach your note to the consult code.
• On first visits with treatments and all subsequent visits regarding that treatment, attach your note to
the original treatment code.
In the image above, the tx code shows the date of completion and the notes display the date of each visit, building a clear history of progress on the treatment.
General Notes
How
Click on the General Note button on the right side of the TX History window.
When
• writing general review notes not associated with specific tx
• By faculty and hygienists when writing observations or recommendations before tx is added to patient
record
• By providers when multiple tx are put inprocess or completed on the same day.
If a tx note is attached to a single tx, the note will not
display if the Tx History window is sorted to a limited
site view that doesn’t include that tx. General Notes
remain on display even with site number sorts.
13
AxiUm Cheat Sheet for Charting Findings (Existing Conditions and Restorations) Student Rolodex ‐Open Patient Record Type in last name, first name, OR chart number, press enter. (You can type in just a few letters of the last name to bring up all matching patient names.) Double click so name is in bottom window. Verify proper patient through date of birth and phone number. EHR‐ Chart Age of Teeth & Missing Teeth 1. In odontogram, click to select tooth or teeth, right click and choose Age Change or Missing. May also use right click‐ Select Teeth ‐to choose All Teeth or Maxillary or Mandibular Arch. Add Findings Via Chart Add Tab 2. Click on (top right of window) to open tab. In Chart Add tab, click on 3. Add Restorations – Click on Restorations/Caries category to add existing restorations, sealants, temporary materials, implants and bridges. Use First tab‐ Quick List‐ (go to Full list if not found here) Choose type of restoration‐ select tooth surfaces in odontogram‐ hit Add Finding button
Text should appear at right in blue text‐ E in status column ‐existing restoration 4. Add Caries‐ In same category, scroll down Quick List to find caries description, highlight it‐ select surfaces from odontogram (red cross hatch appears) hit Add Finding button
Text should appear in blue text‐ status A‐ existing caries‐ red cross hatching in odontogram 5. Add Conditions ‐(Tipped teeth, diastema, impacted, etc.) Choose Conditions category‐ select condition from Quick List‐ select tooth in odontogram‐ hit Add finding button. Text should appear at right with status A for existing condition. T o delete a finding, highlight the text, select button with red X. When finished, have faculty approve‐ text will display as pink once approved. 05/12 14
15
Get Patient Approval
**Patient signs
treatment plan and
medical history form
Student/ Patient
(Plans sub tab). Click on
(direct right) to begin new plan.
Add a new Note from direct right- Code
button, double click UGOD template- OK, fill in note.
chart # box is still aqua, click on it again and click on
,
,
chart # button must be grey when finished.
,
, click
print patient copy and close window to bring up patient signature box. Have patient sign Treatment Plan estimate. Go to
- Click
. Faculty will review TX Plan and approve. Click on Close.
Go to computer with printer at front of clinic. Open patient record, in
5. Click on
4. If you completed more than one form, select All Pages. Faculty will approve. Close the EPR window.
to
to bring
. Your patient’s Medical History (and any other
forms you completed) will come up for faculty to review. Make sure faculty reviews every form you completed. Hit
up Form Approval window. There could be up to 6 forms (Head & Neck exam, Caries Risk, etc.)
3. If
1. Click on
(chart # box, bottom of screen). Faculty will review findings and approve.
2. If you have written any notes, they will pop up. Faculty will review note and approve.
Click on
, select
Note requires faculty approval.
To delete a procedure, highlight and hit
When done, highlight selected TX, right click, choose Assign, add Phase and
Sequence. Both faculty and patient approval required.
.
. Double-click on diagnosis, choose Quick or Full List, choose Category, single-click on Tx
choice or click on + to open folder of options and select Tx. Select tooth, teeth or surfaces if required. Click on
Detailed Plan Sub Tab: Click on
to add problems. Highlight
to add diagnoses. Double click to add diagnosis to bottom table, click OK to exit. Diagnoses
, makes sure problem(s) shows in bottom table. X to close window.
Diagnosis Sub Tab: Click on
must show in bottom window.
problem, click on
Problems sub tab: Enter plan name, Patient’s Chief Concerns (in their own words) click on
Click on
click
at bottom of Medical History Form. Have patient sign medical history form.
Escort patient to patient accounts window to complete billing.
Altering Approved Tx
Student and
Click on
tab. Select the line of TX that needs change and double click. Click on
next to Code that needs editing and
Plans (Must have faculty
Faculty
make corrections or alter Tx Status. Only surfaces and materials can be modified. Other changes require a new TX Plan and
and patient approval to
patient approval. OK to exit from window. Requires faculty approval. To delete the Tx, faculty must log in and delete. All changes
view tx in Tx History tab)
except deletions will be reflected in the Tx Plan tab, Detailed Plan subtab.
Get Faculty Approvals
**All forms must be
approvedCaries Risk
Assessment, Head &
neck Exam, consults,
perio exam, etc.
and repeat Detailed Plan
steps.
To alter unapproved Tx
Plans, click on ,
It will not display on TX
History until approved by
faculty and patient.
Create TX Plan
Student and
Faculty
Add Note
(see Charting in the
Chart Add Tab sheet
for instructions)
Before starting
Tx Plan1- complete pt
medical history
(forms AMEDHX),
2-take radiographs,
3-Add patient
findings
-caries,
restorations,etc.4- add OD
procedures as
planned
Student
TX Planning for Students (revised 02/02/10)
Adding Planned Treatment
1. Select your patient through the Rolodex. Make sure their name is showing in the message box at the bottom
of the axiUm window.
2. Click on the
3. Select the
4. Select the
Create a New Record button (top right of screen) to open the
tab.
radio button (default).
tab (default).
5. Select the appropriate category from the list on the left.
6. Single click on Tx choice or click on the + to open folder of options. If you do not see the category or Tx you
tab and repeat steps 4-6. If you want to add phasing and sequencing here, double
need, select the
click the selection to jump from the Codes subtab to the details subtab. Do NOT enter the sites and surfaces
by typing in the code.
7. Select the tooth &/or surfaces where required by clicking on the tooth on the odontogram or selecting the
quadrant when prompted.
8. Click on the
Planned Tx button. Do not add Tx as Inprocess or Complete if you are going to generate a
Tx Contract as it will not be included. Only Planned Tx displays on the contract.
9. To correct an error, delete the incorrect entry by highlighting the incorrect entry and clicking on the
Delete Record button. Then add the correct Tx.
See instructions on approving treatment and printing a treatment estimate.
16
Completing and Approving Treatment (Updated 06/10)
EHR,
a line of planned TX and double click.
3. Move Status from Planned to In Process or to Complete.
1. With patient selected, open
tab.
Students change View to Planned/InProcess for faculty review.
2. Select
4. Click
OK. For students, the treatment will now appear in blue on the Tx History screen indicating that it requires
approval. For faculty and residents, the treatment automatically is approved and goes to billing.
5. To send the treatments to billing, faculty MUST approve the change. Click on the aqua-colored chart box at the bottom
of the screen.
6. This
opens the Check Out Patient window. Faculty approve by entering their approval code, moving all highlighted tx to
the Claim screen on the bottom, signifying that the treatment charges have gone to Billing.
Faculty does not have to OK all changes. They can use the ctrl or shift key to select only those items they wish to approve.
7. Click close and the screen closes, the approved lines of treatment turn from blue to black, and the chart number box (if
emptied) turns to grey.
17
Finding Forms
Forms can be accessed in two places in axiUm: the Forms tab and the Attachments tab. This document serves
to distinguish where users can find forms rather than how to complete them.
Forms Tab
• Open
EHR
• Click on Forms tab
Create a New
• Click on the
Record or Add Patient Form
button on top toolbar.
• Select a form from the dropdown list.
Some forms, like Medical History,
will not be available in the dropdown list once data is added to
the form. Rather, the form will
display in the Forms on File window. Click on the form there and
modify. Changes will be saved with a new date.
Attachments Tab
• Open
EHR and click on
Attachments tab (or click on
the Attachments button
on the left)
• Default is Consent Forms
the Create a New
• Click on
Record button
the ellipses button
• Click on
• Doubleclick on the desired form
• Click OK and then complete the form
You can download PDF copies of the forms
by setting your computer’s default printer to
PDF and then printing out the forms.
18
axiUm Treatment Entry for Perio ModuleStep by Step
Open patient chart in Rolodex1.
screen, some will forward automatically,
some values require choosing a site first.
Defaults to beginning with Max right-max
left-mand left-mand right
Open the Perio Charting
6.
module
you will see the most
recent exam displayed.
2. Hit the create new record button
Resume entry window appears.
To enter a completely new chart select
‘No’, to resume an old chart click ‘Yes’.
3. Select Perio Date window appears.
New: To open the Add Perio window
without resuming any of the items in the
list.
Resume: To allow users to select an
incomplete chart and resume it. This is
only enabled if the selected chart is
incomplete. This will display the Perio
Add window with data filled in from the
chart selected.
Edit/Review: To allow users to select an
incomplete chart, review it and possibly
make corrections. When selected,
displays the Perio Add window for the
selected date with the title Edit Perio, the
Chart Date enabled and the data filled in
like when in Resume mode.
Close Off : This closes off an incomplete
chart so that they can no longer be edited.
Re-Open: Undoes the closing off of a
chart and allows it to be edited. Both
Close Off and Re-Open will add another
line in the list with today’s date in the
Audit Date column.
Note :The difference between Edit and
Resume is that Edit keeps the perio
date as of the date it was first entered.
Resume updates the perio date to today.
4. Choose Exam type from the drop
down
(Initial exam, complete exam. Postscaling, etc.)
5.
Enter the values for each category
by using the keyboard or selecting the
values on the display
To Save: To save your
work as you go along.
Clear All: To clear all entries since you last
saved.
Clear: Clears the current cell (but does not auto
advance so that the user may re-enter the proper
value).
Clr Tooth: To clear all 3 values for the tooth.
For Yes/No conditions, resets them to their "No"
value.
To save and close a chart
that you wish to resume at a later date
To save a completed
chart,does NOT allow re-entry at a later
date to resume the exam
Toolbar buttons:
View form history, view a list of
forms and see which ones are complete or
incomplete, can reenter incomplete exams
full mouth view of perio screen
can choose to compare selected
exams graphically or text only
opens the medical history
view attachments (referral letter,
medical release letters)
print exam
select perio display options
Kathy Hansel 504-941-8139/Room 2305
19
Axium- Faculty- Step-by-Step
1) Faculty -Start Check- appointment must be in scheduler first,
2) click on red student name button
at lower left, review appointed treatments in
right side of window, enter approval code- (semicolon; - 4 character code- Enter)
3) student name button turns green (add to or change appointed treatments by using arrow keys )
When student has completed procedures,
4) Go to In Progress or Tx History tab and change procedure from Planned to
In Process or Complete (double click on procedure and change to In process or Complete) text will
turn blue- needs approval
5) Faculty- approve by hitting aqua chart number button
(semicolon; - 4 character codeEnter)
6) Review procedures to be approved,
7) A Treatment Note must be added for every patient visit before student leaves clinic, the note will
display for approval
8) enter approval code (; semicolon before and enter button after 4 character code)
9) Is medical history signed? If
sign at station at front of clinic.
button appears at bottom of med hx form, patient must
10) Grades- choose grade Discipline & Form from drop down box- enter grades
11) enter approval code again (semicolon; - 4 character code- Enter)
If patient does not show and student wants attendance credit- must be entered in student chart
according to how many hours assisted in clinic
Add as complete-C- approval is needed.
Chart number button will turn grey and text of procedure turns black when successfully approved
Faculty approval must be given at every appointment- a procedure (whether complete or in
process) or treatment note must be entered in the chart for every patient visit and approved by
faculty
Approval must be done before bringing patient to cashier, charges are not entered until procedure
status is changed to Complete and Approved.
**To add a grade after a clinic session: When the chart number button is no longer aqua and the
procedure is complete -Go to Tx History tab- select and right click on procedure needing grade- select
Add Student Eval- enter approval code to open grade form- choose discipline and grade form- - enter gradesenter approval code
*******Cheat Sheets and Axium Training for Faculty
See LSU School of Dentistry website- http://www.lsusd.lsuhsc.edu/
Quick Links- Axium Training page has cheat sheets and training videos
Kathy Hansel AxiUm Support
504.941.8139 Room 2305
[email protected]
20
INDICATIONS FOR MEDICAL CONSULTATION
Adrenal Disorders
Angina Pectoris
Allergy to Local Anesthetic
Anticoagulant Therapy
Anemia
Arrhythmias
Asthma
Bacterial Endocarditis
Blood Dycrasias
Cardiac Prosthesis Disease
Cerebrovascular Disease (Stroke or Seizures)
Congestive Heart Failure
Chemotherapy
Cirrhosis
COPD (emphysema)
Diabetes Mellitus
Dialysis
Epilepsy
Hepatitis
Hemorrhagic Tendencies
HIV
Hypertension (> 140/100)
Liver Disease
MAO Inhibitors
Malignancies
Myocardial Infarction
Organic Heart Murmurs
Pregnancy
Prosthetic Joint Replacement
Psychiatric Disorders
Rheumatic Heart Disease
Radiation of Head and Neck
Serum Chemistries
Sexually Transmitted Disease
Steroid Therapy
Thyroid Disease
Tuberculosis
21
LSUHSC School of Dentistry
Medical-Dental Questionnaire
Date:________________________
Name:
SSN:
Address:
City, State, Zip:
Home/Cell:
Occupation:
In Case of Emergency, Contact:
Address
Physician's Name:
Address:
Sex:
axiUm No.___________________
Date of Birth
Race:
Marital Status:
Office Phone:
Name:
Relationship:
City, State, Zip
Phone:
Phone:
Hospital :
City, State, Zip:
Hospital #:
DENTAL HISTORY
1 Are you presently having a toothache / dental pain?
2 Please mark your current level of dental pain:
4
5
6
7
8
9
10
11
12
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Yes
No
Not Sure
3 Briefly explain your present dental problems or concerns:
Do you bleed excessively after tooth extraction?
Have you had pain or swelling for more than two weeks after injury or surgery to the face or jaw?
Any serious reactions to local or general anesthetics (ex: lidocaine, propofol), nitrous oxide?
Have you ever had any serious trouble associated with any previous dental treatment?
If yes, explain:
Do you have any soft tissue sores or bumps in your mouth?
Do you clench or grind your teeth?
Are any teeth sensitive to cold or sweets?
Has a doctor told you to take antibiotics BEFORE having your teeth cleaned or dental treatment?
MEDICAL HISTORY PART 1
Are you being treated by a medical doctor now?
Date of last visit:________________________
Reason:
Are you taking any medications at the present time?
List all:
Have you ever taken medication to relieve anxiety or depression?
Are you sensitive or allergic to any medication or to latex gloves/products?
List:
Have you ever been hospitalized or had any surgical operations?
Have you ever had excessive bleeding from a cut or wound?
Have you ever had cancer? If yes, what kind?_____________________________________________
Do you have pain in the chest upon exertion?
Do you have shortness of breath after mild exercise or exertion?
Do your ankles swell or do you bruise easily?
Do you use extra pillows to help you breathe better while sleeping?
Do you have to urinate (pass water) frequently?
Are you thirsty and/or hungry much of the time?
Have you lost or gained weight (more than 10 lbs) in the last year? Reason:____________________
Has a doctor ever said you had infectious diseases (for example, HIV, hepatitis C, tuberculosis?)
Do you have difficulty with swallowing, breathing, or snoring (sleep apnea)?
Do you have frequent infections?
Do you have frequent headaches or migraines?
Do you currently or have you in the past used tobacco products and/or alcoholic beverages?
If yes, are you interested in a tobacco cessation program?
COMPLETE OTHER SIDE
Ver. 05-2011
This Medical-Dental Questionnaire is created and maintained by the Division of Diagnostic Sciences,
Louisiana State University Health Sciences Center School of Dentistry, New Orleans, Louisiana.
Yes
No
Not Sure
Form P0059
22
Please check the appropriate box for any condition that you have now or have had in the past.
(Parent or Guardian: To complete this form, indicate your dependent’s health status by checking the appropriate boxes below.)
Yes
1. CARDIOVASCULAR
Heart Failure
Heart attack or disease
Angina pectoris or chest pain
Acute coronary syndrome
High blood pressure
Heart murmur
Mitral valve prolapse
Rheumatic fever
Congenital heart defect or lesion
Artifical heart valve
Irregualr heart beat
Heart pacemaker or defibrillator
Heart surgery or transplant
Other heart problems
Stroke
Aneurism
2. BLOOD/ONCOLOGY
Blood Transfusion
Anemia
Sickle cell disease
Leukemia
Clotting disorder or hemophilia
Tendency to bleed longer than normal
Chemotherapy
Radiation treatment
MEDICAL HISTORY PART 2
Not
No
Sure
Yes
No
6. RESPIRATORY
Chronic bronchitis
Emphysema
Asthma
Respiratory allergies
Chronic cough
Sinus trouble
Tuberculosis (TB)
Breathing difficulties
Flu-like symptoms
7. SKIN / MUCOSA / MUSCULOSKELETAL
Allergy to latex (rubber gloves)
Skin rash
Dark mole(s) or recent changes
Melanoma
Fibromyalgia
Sore muscles
Stiff joints
Arthritis or gout
Artificial joint
Osteoporosis
Medicines for osteoporosis/bone cancer
Intravenous (IV) bisphosphonates
8. GENITOURINARY
Diabetes
Thyroid disease
Steroid therapy
Sexually transmitted disease (STDs):
syphilis, gonorrhea, genital herpes,
chlamydia, HIV+ / AIDS
Kidney (renal) dialysis
Kidney/bladder problem
Urinate frequently
4. NEURAL/PSYCHIATRIC
9. ORAL MEDICINE / FACIAL PAIN
3. ENDOCRINE
Eye pain
Vision Problems
Glaucoma
Earaches/ringing in ears
Hearing loss
Severe headaches
Fainting or dizzy spells
Epilepsy, seizures, or convulsions
Nervousness
Psychiatric treatment
Depression
Schizophrenia
Bipolar
Alcohol or substance abuse
Not
Sure
Mouth ulcers and candidiasis
White/red patches in the mouth
Dry mouth (xerostomia)
Pain in facial muscles
TMJ (jaw joint) problems
Nerve pain (neuralgias)
Autoimmune disorders (Sjogren's, lupus...)
10. OTHER CONDITIONS
Enlarged lymph node or gland
Head and neck cancer
Hyperbaric oxygen therapy
Organ or cell transplant
Disease, problem, or condition not listed?
(Describe here:)
5. GASTROINTESTINAL
Gastritis/ulcers/reflux disease
Ulcerative colitis
Crohn's disease
Pesistent diarrhea/constipation
Hepatitis
Liver disease
Yellow jaundice
Cirrhosis
11. FEMALES
Yes
No
Not
Sure
Are you pregnant now?
Do you plan to become pregnant soon?
Did you have any complications during
pregnancy? (If never pregnant, answer no)
Do you have trouble with your period?
(If you don't menstruate, answer no)
To the best of my knowledge all the answers on both sides of this page are true and correct. If I have a change in my health information,
I will inform my dentist at my next appointment.
Signature of Patient (18 or older)/ Parent / Guardian_____________________________________________Date_________________________
COMPLETE OTHER SIDE
Ver. 05-2011
This Medical-Dental Questionnaire is created and maintained by the Division of Diagnostic Sciences,
Louisiana State University Health Sciences Center School of Dentistry, New Orleans, Louisiana.
Form P0059
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AxiUm Training Exercise 1
Postgraduate Residents
Your laptop on campus:
1) Open Remote Desktop Connection to access axium:
2) Go to Start> All Programs>Accessories> Communications>Remote Desktop
Connection>
3) Type in the address “lsusd-terminal.lsuhsc.edu” next to computer. Hit Connect.
4) Use your LSU username and password again.
5) Once the home page appears, click on the Axium icon
6) use your axium username and password in the user authentication window
*Off campus- open LSUSD website- http://www.lsusd.lsuhsc.edu/- Quick Links drop
down menu -Citrix connection
Mac users: go to LSUSD website- http://www.lsusd.lsuhsc.edu/-Axium Training page
for remote desktop download and citrix link)
Username: first letter of first name, first 5 letters of last name or LSU username
Password: axium
After first login, go to Tools (on toolbar)- change password
To find your assigned patient:
Click on Personal Planner icon
Click on Assigned Patients tab and hit magnifying glass to search for the patient
assigned to you. Click on name in list and right click- Select patient- will open the
patient record, name appears in bottom status bar.
What is your patient’s chart number? ___________
To open patient’s chart outside of Personal Planner:
Go to Rolodex module- type in last name of your patient (Training) or chart
number and hit enter. Rolodex card for this patient opens.
Click on red Alert button to view medical alerts for this patient.
Close window (red X).
Go to EHR module: will open to Forms tab- Adult Medical History 2011 form
Forms tab- Review medical history:
See
at the top of the form. Questions with
a Yes answer in the medical history will appear here- Yes answered questions in
the medical history appear in RED text–
What medical alerts are listed in top right next to odontogram? _____________
if you see this message in Alerts,
you must open
the medical release letter to see if there are any limitations to treatment:
To view the med release letter, go to the second tab- Medical summary tabscroll down to see Medical Consult- click ON FILE to view letter.
Any precautions listed at bottom of sheet? ______________________________
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AxiUm Training Exercise for Residents
Go to line in Medical History- List any meds w/brand (generic) dosage
Double click so that text box opens
Add “aspirin daily, Claritin as needed”
Go to next line in form, you should see updated meds in Current Medications at top
right next to odontogram
scroll down to view entire medical history form
button appears because patient must sign medical history initially and
whenever changes are made.
Click on each tab in the bottom half of EHR to become familiar with info
found thereIn Progress- Today’s Activities, Pending treatment, health summary
Tx History- Existing restorations, caries, notes completed in process and planned
treatment, upcoming recalls and appointments
Forms- medical history, consults, Forms on File list on right
Attachments- consents, medical release letters, photos
Perio- perio charts
Tx Plan- Phase 1 and 2 treatment plans added at initial OD for Undergrads only
tab allows entry of Findings and Planned treatment
click on Create new Record button
on top toolbar to open Chart Add tab.
Add Findings: Click on Findings button (left of screen above category) to add
findings for a new patient (existing conditions & restorations)
Right click on tooth # 1,16, and 32 in odontogram and mark as Missing.
Indicate that #17 is impacted (conditions- impacted-choose tooth- add finding
button)
Add an existing amalgam restoration on Occlusal surface of tooth #30. Choose
M-AMAL, then choose Occlusal surface on tooth #30 in odontogram, then add
finding button
Add existing composites (caries/rest) on mesial surfaces of #7 and #8.
Add primary caries as a finding on Occlusal surface of tooth #2 and #14. Occlusal
surface on odontogram for teeth 2 and 14- Add finding button.
Right click on tooth #12 and change to primary tooth (age change).
Add Planned treatment: Choose Dental Txs button to add planned treatment.
Add a prophy by choosing Preventive category-Adult Prophy from Quick List and
Hit planned treatment button
- tooth with yellow P
Add 4 bitewings by choosing Diagnostics category- Bitewings, four films from
Quick List, hit planned treatment button.
Add an amalgam on tooth #14- Operative category-D2140- Occlusal surface on
#14 in odontogram, planned treatment button
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AxiUm Training Exercise for Residents
Text for these procedures will be blue because faculty approval is needed. Chart
number button in status bar at bottom of screen turns aqua also.
Yellow dot on tooth surface in odontogram means planned treatment procedure.
Go back to In progress and Tx history to view planned treatment.
Add Treatment Notes:
Clinical Notes: Add note by right clicking on a procedure in the Tx History tab -
Add Tx NoteNotes can be entered as General notes (free style), Template note (must
choose a template for that department) , or SOAP notes.
Template note- hit ellipsis button next to Codechoose a
note - double click to add to bottom of window.
Note guide appears in window-Complete information in note. Hit OK.
If no procedure was done, hit
button on right toolbar to add note.
Select General noteAdd note “Patient came to clinic in pain.
took radiograph #24- sent to PG endo clinic for evaluation for endo.”
To add SOAP notes- select
- select SOAP note- add information to all four
sections of SOAP note- OK to save and close.
To add a note to a tooth: right click on tooth #7 in odontogram- add note
“composite discolored”- Note should appear in TX History
Print Treatment Estimate: once planned treatment has been entered and approved,
you can print a treatment estimate – go to the Tx History tab- hit the
button on
the lower right toolbar in the Tx History tab- Select All or you can select which
procedures you want and hit Ok- it displays an amount for the selected procedures.
Lexi-Comp Online- Drug Database Search
Go to Links (top toolbar)
Axium Help TrainingGo to Links (top toolbar)- link will open axium training page on LSUHSC School of
Dentistry with cheat sheets and training videos
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AxiUm Training Exercise for Residents
Add a Form (consult or new medical history):
Go to Forms tab- hit Add Forms button on top toolbar
CNS- consult (ENDORE is for referral to PG endo, SURGRE is for referral to PG
Oral Surgery)
Complete the form as if you were called to undergrad clinic for a consult for your
department.
To open an existing form, click on date of the form or next to the form under
on right.
View Appointments:Go to Scheduler module
Will open to your scheduling book
Click on book icon
in upper right hand corner of scheduler screen to select another
book (if available)
Click on green date button at bottom of window- calendar appears- select another date to
view
Find a date when you have patients in your schedule- right click on the appointment slotallows you to go to Patient card- Select patient opens the patient record.
print a list of appointments or recalls in various date ranges- hit Search to run
report after setting date range- will default to your provider code.
Print view
at bottom of window allows you to print schedule.
View upcoming appointments for patient:
Click on patient name in status bar at bottom of screen, appointments can be viewed
at bottom of Patient Card window.
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AxiUm Training Exercise 2
New Residents
Your laptop on campus:
Remote Desktop connection
*Clinic laptops: just click on axium icon on desktop.
**Off Campus: LSUSD website- Quick Links- Citrix
Go to Rolodex module- select patient from workpad list on right or type in
last name or chart # and hit enter. Chart is open when name appears in status bar
at bottom of screen.
Go to EHR module:
For a New Patient- to chart caries/restorations already there:
Add Findings: click on Create new Record button
on top toolbar to
open Chart Add tab. Click on Findings radio button to add findings for a
patient (existing conditions & restorations)
Add caries and existing restorations as shown: select code from quick
list select tooth surface in odontogram
Add finding from toolbar
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When complete, odontogram should match image below:
When all findings have been charted, student/resident will plan treatment for patient.
Adding Planned Treatment
Add a planned endo on tooth #8 and 9,
Practice using the Expert subtab by going to the first subtab- Expert in the
Chart add tabSelect a Diagnosis- PA abscess select tooth 8 & 9 in odontogram
D3310in procedures
button here)
Planned treatment **(do not use Add finding
Add remaining planned treatment as shown:
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Odontogram should look like this.
Go back to In progress and Tx history to view planned treatment.
If planned treatment is blue instead of red (approved), let Kathy Hansel know so
that she can approve it. Planned treatment must appear in red, meaning that it has
been approved before proceeding to next section.
Some departments allow postgrad residents to automatically approve planned treatment,
others require faculty approval first.
Changing planned treatment to In process or Complete
Go to the In Progress tab- (first tab)
Under Pending Treatments, you should see planned treatments in red text. P in status
column means planned treatment.
Double click on crown procedures for 8 and 9 and change to In Process (I status).
For each visit when fixed/removable/endo procedures are in process, status should be
In process.
Double click on each of the remaining planned procedures and change status to
Complete.
(If your planned procedures are still blue, raise your hand and I will approve them)
Status column will now have I or C to indicate In Process or Complete and text turns
blue (unapproved) , black (approved) or brown (in process & approved).
Blue text must be approved by faculty.
Very Important: Charges and billing will not be complete until the status of the
procedure is changed to complete and approved (black text).
Add Treatment Note:
Right click on the crown procedure you just changed to InProcess- Add NoteTemplate-Code- choose PGPROS note template- fill in note- hit OK
Click on aqua chart # button to see what needs approval.
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Go to the Attachments tab
or the
module on the
left side of the screen- go to the Consent Forms section to see if the patient has
signed an Endo Consent form- Yes or No
Open and complete Forms for patient
Click on Add Form
button on upper right toolbar in EHR- select form with drop
down arrows.
Complete the following forms according to your department:
PG Perio- PEREF & PATH
PG Endo- ENCONS & PATH
PG Pedo- PCE 2
Oral Surgery - SURGRE
PG Pros and GPR- CNS & PATH
Add a contact note for your patient:
Patient card- hit name on status bar- contact notes icon
type in “wrong phone number” in the Note text window- hit create new record button
to save
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Go to the Patient Care module
- all records for a patient in one screentext format
Change the date range to start at 01/01/10- drop down arrow next to View allows you
to select records to view- hit Search
All appointments, notes, treatment will display if All Records View is chosen.
Production Report:
Go to Info Manager
- custom button
select Production Report- Print- click on report type- select from drop down- click
on date range- select date range- OK-view production report- completed procedures
only.
Send an internal message to Kathy Hansel when both training exercises are
complete.
Hit envelope in status bar at bottom of screen
Hit create new record button
- type in Hansel in the To field and Training
exercise in the subject field, in the text window, type “I am finished”. Send
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