Efficient Visit Documentation for Medical Workflow Optimization

1. Out the Door(Overview) Chapter 12

2. Objective • Understand the Visit Documentation screen

3. Key Concepts • Subjective • Objective • Assessment • Plan • SOAP notes • Right information to the right person at the right time • Targeted information • Blink speed • Visit documentation • Out the door • Evaluation and management(E/M)-also referred to as the level of service

4. Out The Door • Efficient medical workflow-minimizes time takes physician to document subjective/objective findings based on exam, assessment of condition and plan for treatment • These components=SOAP • Subjective • Objective • Assessment • Plan

5. Out The Door • Present the right information to the right person at the right time • MedTrak does this by presenting only information needed at the time to make decision when requested. • Reduces clutter on screen so clinicians can focus on targeted information • Reduces weight of each screen-amount of data downloaded which allows instantaneous screen changes

6. Streamlined • MedTrak streamlines order entry process by problem-focusing the order selection screens to present most likely orders that physician would need for presenting problem(s) with minimal clicks of mouse

7. Presenting Targeted Information • MedTrak developed processor for physicians to use visit documentation which includes these sections: • Additional orders needed for patient’s care • Referrals to specialists/specialized testing • Diagnosing • Documenting the history/exam findings(subjective/objective data) • Aftercare instructions for patient to take • Evaluation and management(E/M) level of service

8. Documentation Screen • Place cursor next to patient’s name click Out The Door button • Term originated when MedTrak was being developed to run the emergency department of a hospital. During visits to ER we would hear physicians telling ward clerk that they were done with patients and wanted them “out the door.”

9. Two-Minute Drill • Goal was to have physicians place additional orders, order a referral, enter patient’s diagnosis, prescribe for patient, provide patient with aftercare instructions and select patient’s level of service in 2 minutes are less • This was achieved without documenting the history and exam portions-which are the only 2 portions that do not have to be documented before the patient leaves the facility as no charges relate to these

10. Out The Door Review • Visit documentation screen enables physician to document patient’s visit by working down the section on screen • Screen refreshes as physician documents to show the work • Top of screen displays date of service for visit, clinical staff’s answer to medication allergies questions, patient’s name, reason for visit

11. Figure 12-1

12. Orders • Enables physician to: • Place additional orders using problem-focused order entry method • Place additional orders using order codes than can be entered directly on screen • Cancel an order • Access the open orders processor to document an order

13. Referral/Authorizations • Enables the physician to: • Place an order for patient to see specialist (orthopedic surgeon, dermatologist, etc.) • Place an order for physical therapy, occupational therapy, chiropractic care • Place an order for MRI, CT scan, EMG or other scheduled testing

14. Diagnosis • Enable physician to choose, maintain the diagnoses using: • Problem-focused diagnoses tree based on physician’s checklist • Find DX process that provides seven different ways to locate diagnosis • Top 60 DX process that displays most common diagnoses on one screen • Add DX process that starts at top of diagnosis tree • Delete DX process to remove a diagnosis

15. History And Exam • Enables physician to document history/exam findings: • History/Exam questions based on diagnosis • Physicians can use check box process with touch-screen tablet • Physicians can use voice recognition software • Physicians can dictate history/exam finding to transcriptionist • Physicians can type answers using keyboard and stored response processor

16. Medications • Enables physician to: • Order both dispensed/prescribed medications using problem-focused order entry process • Order both dispensed/prescribed medications using order codes process • Cancel a medication order

17. Instructions • Enables the physician to select patient’s problem-focused aftercare instructions based on diagnoses. Physician can: • Instruct patient as to what to do at home • Instruct patient as to what to do at work • Document patient’s plan of care • Schedule patient’s next appointment with minimal effort

18. Level Of Service • Enables physician to select level of service for visit: • Based on complexity of history, exam, decision-making for primary care • Based on type of visit for orthopedics • Provides first aid designation for worker’s compensation visits • Provides for consultation visits

19. Done Or Not Done • Enables physician to indicate whether the visit documentation is done or not • Sometimes physicians are interrupted with phone calls from patients, questions from clinical staff and cannot finish documenting the visit at that time • Physician can return to this screen when they have time-however, patient will not be discharged from Clinic Status until physician indicates that he/she is Done with patient and they are “out the door”