|OP sets all defaults to share all information. Any individual decisions by Practice-users to restrict information sharing (access, use, or exchange) are the responsibility of the Practice in the implementation of its 21st Century Cures Act Information Blocking policies and procedures for its Practice and patients.|
Reconciling CDAs gives users the opportunity to compare the clinical information that exists in a patient's chart with the information being provided in the CDA file. There are currently three clinical areas available for incorporation:
- Problem List
Access an Incoming Transition of Care
When a message with an attached CDA is received, the user can view and reconcile the attachment from the following areas of OP:
- The Message Center (Main Navigation Panel > External > Unread External tab):
- Click the attachment button (highlighted in the image below). The Clinical Document Review and Reconciliation window is displayed.
- Proceed to the next section.
- Document Management (Clinical or Practice Management tab > Document Mgmt button):
- Click the New Document button.
- Use the Import Documents drop-down menu to select Import CDA.
- Locate and open the CDA.
- Associate it to a patient using the Patient ID field.
- Select Item Type: Chart: Med Hx.
- Complete any other pertinent fields, and click the Save button.
- Click the Reconcile button. The Clinical Document Review and Reconciliation window is displayed.
- Proceed to the next section.
Regardless of where the user accessed the attachment, the steps to reconcile it are the same.
Reconcile a Referral Transition of Care
When the Clinical Document Review and Reconciliation window opens, the Overview tab is displayed. The user can continue with reviewing and reconciling the CDA.
- Review the Overview tab. This tab serves as a face-sheet for the CDA.
- Attach the CDA to a referral:
- Click the Referrals tab.
- Click the paper clip button on the referral to attach the document. A line is created in the grid indicating that the referral has been associated.
- If a Referral/Transition of Care has not been created, the Create TOC button should be used to open the Referral/Transition of Care window to enter the Transition information. Once that entry is saved, the CDA may be attached.
- Review the Problem List section of the report.
- Click the Problem List tab.
- Review the information provided where clinical information that already existed in the patient's chart is displayed with a blue background, and new clinical information is displayed with a yellow background.
- Choose which information should be incorporated into the patient's chart:
- Select the new clinical information displayed with a yellow background.
- Click the Merge > > button.
- In the Action column, select from the following options:
- Ignore: This is the default for new clinical data.
- Add: Adds the data from the document to the patient's chart.
- Retain: This is the default for the clinical information that already existed in the patient's chart.
- Remove: When regarding new data, this does not incorporate the data into the patient's chart. When regarding existing patient chart data, this removes data from the patient's chart. An example of when this would be done could be if a specialist provided a more granular description of the patient's problem/diagnosis.
- (Optional) Edit the following columns, as needed: Status, Onset Date, Resolved, Privacy, Sort Order, and Hide.
- Click the Review > > button to review the patient's new Problem List.
- If the Problem List is acceptable as is, click the Submit button (an irreversible action), and confirm you want to merge the data. If a change needs to be made, click the < < Merge button to return to the previous screen.
- Repeat the steps above for the Allergies/Rxns and Medications tabs of the report (as applicable).
- Close the Clinical Document Review and Reconciliation window.
- Click the Mark Reviewed button (if accessed from Document Management) or mark the message Read (if accessed from the Message Center).