The Diagnosis 1 (Dx1) and Diagnosis 2 (Dx2) tabs allow a practice to track and treat 2 separate malignancies for a patient. Each tab stores detailed information about the diagnosis and treatment. Information stored on this tab must be entered manually into IntelliDose.
Once a diagnosis has been selected, the following fields will update to display diagnosis specific information.
A. Dx - Diagnoses
Select a diagnosis from the drop-down list by scrolling or entering free-text in the Dx field. A primary diagnosis must be entered prior to assigning therapy. The list of diagnosis may be updated and edited through the IntelliDose setup menu.
If a diagnosis of Breast Cancer, Colorectal cancers or Non-small cell lung cancer is entered, the user will be prompted to add further clinical information to the patient chart.
Add the month and year of diagnosis by selecting from the drop-down list. This information is mandatory for some diagnosis (ex: Non-Hodgkin’s Lymphoma).
C. Associated ICD-9 code
Select and store an ICD-9 code for the primary diagnosis here. This code will be available on each chemotherapy charge encounter associated with the selected diagnosis. Additional secondary diagnosis may be entered in the secondary diagnosis field as described below.
D. Diagnosis pathology
Record the pathology information by selecting from the list available. This information is optional however it is very valuable when using IntelliDose reporting tools.
E. Diagnosis TNM
Enter the TNM classifications from the pathology report in the appropriate fields.
F. Diagnosis stage
Select the patient’s stage of disease from the drop-down list. Stage information must be recorded in the patient record prior to assigning therapy. If the stage is undefined at the initiation of therapy, enter Stage X. When stage X is selected the user will receive an alert to update the stage detail when available. The alert will display each time a new order is initiated until the stage information has been updated in the patient record.
G. Staging Wizard
The staging wizard tool assists users in accurately staging patients. To launch, select the staging wizard button.
The staging wizard allows a user to enter diagnosis specific TNM classifications from the pathology report and generate a stage. This tool is not available for staging schemes with more than 16 stages. Once complete the stage and TNM detail is stored on the Dx1/Dx2 tab.
The progression information tool tracks patient response throughout therapy. Select the Progression information button to record patient status periodically throughout therapy.
From the site progression tool, select the Monitor Progression button to update patient status; record a patient observation; NED (no evidence of disease); Recurrence; Local; or Metastatic. If an observation of Local or metastatic is entered the user is also prompted to input site information prior to recording the progression information.
Information entered through the disease monitoring tool may be reviewed on the site progression table launched from the Dx1/Dx2 tab.
When therapy is initiated the user is prompted to enter a simple plan for radiation, surgery and treatment intent. The information recorded may be viewed or updated in this section of the patient record.
The treatment history box displays a snapshot view of the patient’s therapy. This will remain blank until the first line of therapy has been assigned to the patient. Therapy is most commonly assigned and managed from the Orders tab. However, the prescriber does have the ability to assign therapy from the Dx1/Dx2 tab if necessary.
New - The new button will allow the user to assign therapy to the patient. T
Undo - Use the undo task on the Dx1/Dx2 tab to remove a treatment plan from the patient’s current therapy. The undo button on the Dx1/Dx2 tab may only be used to remove a therapy if all orders in the plan are in an unwritten status.
Show Plan - This button will open the Orders tab displaying the plan in more detail.
The Secondary Diagnosis box stores the ICD-09 codes for each of a patient’s secondary diagnosis. This portion of the record is most important for those practices using the IntelliCharge module. All ICD-09 codes stored on the Dx1/Dx2 tab will display on the ‘close encounter’ dialogue to allow a user to assign to the encounter. Adding commonly used secondary diagnosis codes to the patient record will allow the nursing staff to efficiently complete the close encounter charting step.
Short list - When the patient record is created, the secondary diagnosis box displays the short list of most commonly used secondary diagnosis. These should be assigned to each patient as necessary.
To assign a secondary diagnosis to the patient, locate it in the short list and place a check in the box. A user may select multiple secondary diagnoses at one time as well as update the information as the patient progresses through therapy.
Search - Use the search feature to locate ICD-09 codes that do not appear in the short list. Place a check in the box next to ‘search’ to open the ICD-09 code search screen.
The search may be conducted by entering a text description (i.e. nausea) in the search field or the ICD-09 code. The secondary diagnosis field will update to display all matching results. Place a check next to the appropriate code to store in the patient record.
Through the setup menu, each practice can create a list of open clinical trials. To designate that a patient is enrolled in a clinical trial select the trial from the available list. Initially, when the record is open the clinical trial field presents a blank display. Uncheck the box labeled Show Selected Clinical Trials. Locate a clinical trial in the list and designate enrollment by checking the appropriate box.
This designation will assist users in reporting on patients enrolled in a specific trial.
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© 2011 IntelliDose. All rights reserved. IntelliDose is a Division of IntrinsiQ, LLC. No portion of this publication may be copied, reproduced or incorporated into any other media without IntrinsiQ’s prior written consent. Portions Copyright © 2011 Cerner Multum, Inc. All rights reserved