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Patient Intake

Patient Intake. Chapter 9. Locate a patient on the Clinic Status Screen Move a patient to a room Review the Clinical Note Processor Add and/or delete Clinical Notes Answer an expanded answer question Answer a question with a stored response View the on-line chart

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Patient Intake

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  1. Patient Intake Chapter 9

  2. Locate a patient on the Clinic Status Screen Move a patient to a room Review the Clinical Note Processor Add and/or delete Clinical Notes Answer an expanded answer question Answer a question with a stored response View the on-line chart Put the chart in the rack for the physician Objectives

  3. Reason(s) for visiting • Medical history • Vital signs • Real reason for visit • Presenting problem • Answer field • Expanded answer • Standard answers • Triggers • Stores responses • Normal answers • On-line chart • Rack Key Concepts

  4. Medical office workflow categories

  5. After registration, patients wait in reception area for you to place them in exam room • In exam room they will be asked some health-related questions prior to seeing the physician such as: • Reason(s) for seeing the physician/chief complaint(s) • History of chief complaint(s) • Symptoms • Previous medical history, injuries or illnesses • Current prescriptions, OTC meds • Vital signs(B/P, heart rate, respiration, temperature) • Body statistics (height, weight) • Other nursing observations Patient Intake

  6. Prior to moving the patient into exam room, visually check to see which rooms are available, and then check the Clinic Status screen for confirmation of availability • Figure 9-2 • Get patient’s paperwork from front desk • Some clinics will use paper charts to supplement the EMR and/or store papers they do not want to store in the EHR Checking Room Availability

  7. On the way to get patient, move the patient on the Clinic Status screen from the waiting room to an exam room. • Click on Clinic Status screen, place cursor next to patient and click and exam room button • MedTrak will reset the clinical staff (TC) column waiting time to zero, indicating that you have begun the patients intake. • Do This! Pg. 124 Moving A Patient To A Room

  8. Once you move patients to an exam room, ask them their reason(s) for visiting the medical facility, medical history & medication history • Record the patient’s vital signs and body statistics • Depending on the practice these may be printed on a clinical note or answered in real-time directly into MedTrak • If office uses MedTrak clinical notes printout, staff member will write the answers on this form and enter them into the system-Figure 9-9 • Sometimes patients will not tell front desk or clinical staff the real reason for visit. Since MedTrak is problem-focused, the checklist questions for the clinical staff and physician are based on the presenting problem(s) selected by the front desk and or clinical staff. It is medically important to ensure the Clinical Note Processor presenting problem(s) are accurate. Do This! Pg. 125 Reason(s) For Visiting The Medical Office

  9. After verifying the accuracy of the presenting problem(s) selected and displayed on Clinical Note Processor Screen, answer the clinical notes questions for patient. Place cursor next to any presenting problems and click Enter Answers button • If there are multiple presenting problems, place cursor next to any of them • Do This! Pg. 126 Answering Clinical Questions

  10. Next to appear is Clinical Notes screen-Figure 9-5 • Lists all presenting problem(s) questions • MedTrak automatically loads the answer for the Chief Complaint question from visit information entered by front desk • If it is inaccurate, change it. • Each answer field hold ten characters • Many will fit into this field but you can click the Expanded Answer button for an answer that is longer than ten characters Clinical Notes Screen

  11. With cursor in answer field for the History of Injury question, you can click Expanded Answer button • Next screen to appear is Expanded Answer screen • Enter information here in three ways: • Typing directly into the field • Cutting and pasting information from another document • Using voice recognition software/microphone to dictate directly into the field • The Clinical Notes screen refreshes, displaying the answer to the right of the History of Injury question • Figure 9-6 • Do This! Pg. 128 Expanded Answers

  12. Placing cursor in answer field for Symptom question and clicking Expanded Answer button then type what is seen in the expanded answer field Figure 9-8 • After entering the answer in the Expanded Answer screen, click Submit Answer button • Clinical Notes screen reappears displaying answer to the right of the Symptoms question Figure 9-9 • Do This! Pg. 130 & 131 Clinical Notes

  13. Normal answers are a subset of standard questions available for a question • MedTrak allows for normal answers by clicking the Normal Answer button. Not all questions will have a normal answer • Example: Prescription Meds question’s normal answer is NONE-meaning patient is not taking any prescription medications • MedTrak automatically answers NONE and moves cursor down to next answer field-this helps to save time • As you get experience you will type little “n” and tab down to the next question-Figure 9-12 • MedTrak stores answers on screen before displaying the next screen • Do This! Pg. 133 Normal Answers

  14. Notice that some questions are related to an injury • These problem-focused questions are part of MedTrak’s clinical decision support (CDS) rules, which comply with Core Measure 11 of Meaningful Use • Enter normal answers for those questions where normal answers apply-Figure 9-14 • Enter body statistics for patient using drop down list to select-Press Enter key • MedTrak will calculate and display body mass index for patient which complies with Core Measure 8 of Meaningful Use • After entering blood pressure, click Page Down button to go tot last Clinical Notes screen • Do This! Pg. 134, 135 Clinical Notes

  15. Enter the rest of vital signs for patient • Type “none” in Nursing Observations-Notes field and click the Submit Answers button • Clinical Notes screen refreshes showing answers to the right of questions-Figure 9-17 • Review answers on previous screen click Page Up button again to return to first Clinical Notes screen to review answers-Figure 9-18 • At any time during this process the on-line chart can be reviewed by clicking On-line Chart button • To exit on-line chart, click Exit Chart button-Figure 9-20 • Do This! Pg. 136, 139 Clinical Notes

  16. Now you need to notify physician that patient is ready to be seen • Indicate on the Clinic Status screen that the chart is now in rack by clicking “RACK” button • You will see “Rack status set” message at top of screen • Click Exit screen button to return to Clinic Status screen to see what you need to do for next patient-Figure 9-22 • Do This! Pg. 141 Letting The Physician Know That The Patient Is Ready

  17. Access visit log for patient’s visit by placing cursor in command field next to patient and click Visit Log button • This is a record of the patient’s workflow steps accomplished to date • This log is another audit log that complies with Core Measure 15 of Meaningful Use • In any one of the command fields on visit log type print chart command “prch” and press ENTER-Figure 9-23 • Do This! Pg. 142 Printing The Patient’s Chart

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