How do the components of a chart note relate to Meaningful Use?

Below you will find information on how each section of the chart note relates to the Meaningful Use objectives.

Why do I need to select an Encounter Type?
Encounter type is used to determine whether a specific chart note should be included in the calculations for Meaningful Use and Electronic Clinical Quality Measures (eCQMs). For an encounter to be included in your Meaningful Use calculations, you must select Office Visit, Home Visit, Telemedicine Visit, or Nursing Home Visit from the Encounter type drop-down menu. The encounter type defaults to Office Visit.



How do Clinical Decision Support notifications relate to Meaningful Use?
For patients who meet certain criteria, you may see clinical decision support notifications at the top of the note. For the Stage 2 Objective 2: Clinical Decision Support, providers must have at least five CDS rules enabled for the entire EHR reporting period in addition to drug interaction alerts. Practice Fusion has all available CDS rules enabled by default, so no action is required to receive credit for these measures.




Do I need to enter a Chief Complaint?
The Chief Complaint section is a free text field. Providers are not required to enter in data in this section in order to meet the requirements of any Meaningful Use objectives, or the clinical quality measures.



Do I need to complete Flowsheets (vital signs)?
The Flowsheets (vital signs) section can be used to enter in vital sign data for patients in a structured format. While this data is not required for any Meaningful Use objectives, we recommend entering the applicable information for each visit. This data is used as part of the requirements. Please note that this data is also used as part of the data requirements for several of the eCQMs. For more information on how eCQMs are calculated using data from this section of the chart note, please refer to the Practice Fusion 2015 eCQM Calculation Guide.

Am I required to enter information in the SOAP text fields?
Providers are not required to enter in data in the S, O, A, and P free text fields in order to meet the requirements of the Meaningful Use objectives and measures. Data entered in this section is not structured and cannot be used for calculating eCQMs.

How do the Screenings/Intervention/Assessments relate to Meaningful Use?
This section of the chart note allows you to document screenings, interventions, and assessments as structured data. All of the data elements that can be entered in this section are associated with a coded value (e.g.: SNOMED, LOINC, or CPT). This structured data can be used to calculate eCQM values and is also shared with patients via the PHR. For more information on how eCQMs are calculated using data from this section of the chart note, please refer to the Practice Fusion 2015 eCQM Calculation Guide.

Do I need to enter Observations for Meaningful Use?
Providers do not need to enter data into the free text fields or check the No impairment box for Functional Status and Cognitive Status in order to meet the requirements of the Meaningful Use objectives and measures. Structured functional assessments results, which are used for one of the eCQMs, must be entered in the Screenings/Intervention/Assessments section of the chart note.

How does the Quality of Care section relate to Meaningful Use?
Data recorded in the Quality of Care section is used by multiple Meaningful Use objectives and eCQMs:

The Medication Reconciliation checkbox is used to indicate when you have reconciled a patient’s medications during an office visit. This checkbox is used to meet the requirements of the Stage 2 Objective 7: Medication Reconciliation.

The Documentation of Current Medications checkbox is available so that a provider can indicate that they have updated the patient’s medication record or can attest that the patient’s medication record is up to date for each particular encounter. This checkbox is used as part of the requirements for the Documentation of Current Medications (CMS 68v6) eCQM. For more information on how CQMs are calculated using data from this section of the chart note, please refer to the Practice Fusion 2015 CQM Calculation Guide.

The Transfer of Care - Incoming checkbox is used to indicate that a particular encounter is an incoming transition of care, meaning this patient was transferred to you from another facility or provider. This checkbox is used as part of the calculations for Stage 2 Objective 7: Medication Reconciliation.

The Transfer of Care - Outgoing checkbox is used to indicate that a particular encounter is an outgoing transition of care, meaning you are transferring this patient to another facility or referring them to another provider. This checkbox is used as part of the calculations for Stage 2 Objective 5: Health Information Exchange. Please note that you should also create a clinical document and attach if to a referral to your colleague.



Do I need to complete the Care Plan for Meaningful Use?
This is a free text field where you can record the care plan for a patient. Providers do not need to enter data into these fields in order to meet the requirements of the Meaningful Use objectives and measures.

More information
Visit our Meaningful Use Resource Center for additional information and to view our Meaningful Use video tutorials. 

Meaningful Use

  1. What is Meaningful Use?
  2. How do I attest for Meaningful Use?
  3. How does the Meaningful Use Dashboard work?
  4. 2018 Medicaid Meaningful Use Stage 2 Objective 1: Protect Patient Health Information
  5. 2018 Medicaid Meaningful Use Stage 2 Objective 2: Clinical Decision Support
  6. 2018 Medicaid Meaningful Use Stage 2 Objective 3: CPOE for Medication, Lab, and Radiology Orders
  7. 2018 Medicaid Meaningful Use Stage 2 Objective 4: Electronic Prescribing (eRx)
  8. 2018 Medicaid Meaningful Use Stage 2 Objective 5: Health Information Exchange
  9. 2018 Medicaid Meaningful Use Stage 2 Objective 6: Patient-Specific Education
  10. 2018 Medicaid Meaningful Use Stage 2 Objective 7: Medication Reconciliation
  11. 2018 Medicaid Meaningful Use Stage 2 Objective 8: Patient Electronic Access
  12. 2018 Medicaid Meaningful Use Stage 2 Objective 9: Secure Electronic Messaging
  13. 2018 Medicaid Meaningful Use Stage 2 Objective 10: Public Health Reporting
  14. 2017 Medicaid Meaningful Use Stage 2 Objective 1: Protect Patient Health Information
  15. 2017 Medicaid Meaningful Use Stage 2 Objective 2: Clinical Decision Support
  16. 2017 Medicaid Meaningful Use Stage 2 Objective 3: CPOE for Medication, Lab, and Radiology Orders
  17. 2017 Medicaid Meaningful Use Stage 2 Objective 4: Electronic Prescribing (eRx)
  18. 2017 Medicaid Meaningful Use Stage 2 Objective 5: Health Information Exchange
  19. 2017 Medicaid Meaningful Use Stage 2 Objective 6: Patient-Specific Education
  20. 2017 Medicaid Meaningful Use Stage 2 Objective 7: Medication Reconciliation
  21. 2017 Medicaid Meaningful Use Stage 2 Objective 8: Patient Electronic Access
  22. 2017 Medicaid Meaningful Use Stage 2 Objective 9: Secure Electronic Messaging
  23. 2017 Medicaid Meaningful Use Stage 2 Objective 10: Public Health Reporting
  24. 2017 Medicaid Meaningful Use Stage 2 Objective 10: Public Health - Immunization Registry Data Submission
  25. 2017 Medicaid Meaningful Use Stage 2 Objective 10: Public Health - Syndromic Surveillance Data Submission
  26. 2017 Medicaid Meaningful Use Stage 2 Objective 10: Public Health - Specialized Registry Reporting
  27. What are the Modified Stage 2 Meaningful Use requirements for 2017?
  28. What are the exclusions for Meaningful Use?
  29. What patients are counted for Meaningful Use?
  30. How do the components of a chart note relate to Meaningful Use?
  31. How do I print the Meaningful Use Dashboard?
  32. How do I minimize or refresh CDS notifications?
  33. How can I send a referral using Direct Messaging?
  34. How does patient portal access and auto-invite relate to Meaningful Use?
  35. What constitutes a "unique" patient?
  36. Meaningful Use attestation for previous years
  37. How do Meaningful Use payment adjustments work?
  38. How do I apply for a Meaningful Use Hardship Exception?
  39. How do I find Practice Fusion's CMS EHR Certification ID?
  40. How do I register for the Medicaid Meaningful Use Program?
  41. Can I change, modify, or cancel my attestation?
  42. How do I choose my reporting period duration for Medicaid Meaningful Use?
  43. Is Practice Fusion a certified EHR?
  44. Patient records maintained in the EHR for Meaningful Use attestation
  45. How do I get my AIU letter from Practice Fusion?
  46. How do I report eCQMs for Medicaid Meaningful Use?
  47. Do I have to meet all 10 objectives to achieve Meaningful Use?
  48. Can I participate in both MIPS (Medicare) and Meaningful Use (Medicaid)?
  49. Are there patient education materials available in Spanish?
  50. How do I select or change my reporting period start date?
  51. When do I need to sign chart notes for Meaningful Use? Can I sign a chart after the reporting period?
  52. How do I contact my state about the Medicaid EHR Incentive Program?
  53. How do I qualify for Meaningful Use if I see patients in multiple locations?
  54. How many exclusions can each provider claim for meaningful use?
  55. How do I use multiple EHR's to qualify for Medicaid Meaningful Use?
  56. What stage of Medicaid Meaningful Use am I in?
  57. How do I prepare for the PQRS Penalty Informal Review?
  58. How do I prepare for a Meaningful Use audit?
  59. How do I batch export patient data from the EHR?
  60. How can I report CQMs for PQRS?
  61. Diabetes: Low Density Lipoprotein (LDL) Management (CMS 163v4)
  62. Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control (CMS 182v5)
  63. Use of Appropriate Medications for Asthma (CMS 126v4)

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