guide to prepping charts - joseph walrath, md€¦ ·...
TRANSCRIPT
We need to choose the proper appointment type, which is "prepped chart". If not, it will increase the risk of a federal penalty for not meeting "Meaningful Use" measures. Anytime we are documenting anything in the chart for a patient who has not yet had a visit utilizing EMR, we have to choose "prepped chart".
1.
We do not associate the "prepped chart" visit with a real clinic appointment. That means don't choose their actual appointment date. Choose the date that the chart is actually being prepped, if over the phone. If the chart is being prepped based on previous paper visit or based on referral documentation, choose the date from the papers as the "prepped chart" date.
2.
3.
Don't choose an actual appointment date from the list at the bottom. Consequently, when you click 'Save', you will get a pop-‐up message that says: "No appointment has been selected. Blah Blah Blah. Are you sure you want to continue?". Click "OK".
4.
No you are looking at the familiar chart for the patient. For prepping, only march along the bottom of the chart, filling out "Ocular Problem List", "Ocular Meds", and "PSFH/ROS"…. Do not fill out "HPI" in a prepped chart.
5.
6.
Remember, in ocular meds (or in system meds section of PSFH), always click "Load Dr. First Meds", because it will auto-‐populate all of the patient medications if the patient has been eprescribed in the past by anyone. If this patient has been referred to us, please click the box labeled "Reconciled Medications", after confirming their medications with dosages. If the patient is uncertain of the dosage, or if prepopulating an established patient from our existing paper chart without dosages, just use the lowest dosage available.
7.
8.
Regarding asking questions about the ROS, I would prefer that we just ask from the following categories, unless anything else seems to make sense: "Constitutional", "Cardiovascular", "Respiratory", "Hematology/Oncology" "HENT", and "Integumentary" . IF A PATIENT REPORTS A CONSTITUTIONAL, CARDIOVASCULAR, OR RESPIRATORY COMPLAINT, PLEASE ADVISE THEM TO CALL THEIR PRIMARY MEDICAL DOCTOR IMMEDIATELY. PLEASE DOCUMENT THIS IN THE PATIENT COMMUNICATION TAB.
9.
We will need to collect the pharmacy information for that patient too. This can be done by opening the "eRx" button in the ocular medication list tab -‐-‐ I think.
10.
If a patient is called during prepping, please also check the "reminder" box in patient communication section of the summary page. ( We will probably have to mark this somewhere in NextGen as well.). This can be seen as an option in the drop down list, on the communications tab of the patient summary. It is labeled "Patient Reminder (MU Stage 1) -‐-‐ see below
11.
12.
Always "Lock Encounter" when you are done with the prepped visit, so that it does not show up in the list of incomplete charts that I need to review.
13.
A few basic principles for preparing charts in advance of clinic:
Guide to Prepping ChartsThursday, April 30, 2015 7:45 AM
We need to choose the proper appointment type, which is "prepped chart". If not, it will increase the risk of a federal penalty for not meeting "Meaningful Use" measures. Anytime we are documenting anything in the chart for a patient who has not yet had a visit utilizing EMR, we have to choose "prepped chart".
1.
We do not associate the "prepped chart" visit with a real clinic appointment. That means don't choose their actual appointment date. Choose the date that the chart is actually being prepped, if over the phone. If the chart is being prepped based on previous paper visit or based on referral documentation, choose the date from the papers as the "prepped chart" date.
2.
3.
Don't choose an actual appointment date from the list at the bottom. Consequently, when you click 'Save', you will get a pop-‐up message that says: "No appointment has been selected. Blah Blah Blah. Are you sure you want to continue?". Click "OK".
4.
No you are looking at the familiar chart for the patient. For prepping, only march along the bottom of the chart, filling out "Ocular Problem List", "Ocular Meds", and "PSFH/ROS"…. Do not fill out "HPI" in a prepped chart.
5.
6.
Remember, in ocular meds (or in system meds section of PSFH), always click "Load Dr. First Meds", because it will auto-‐populate all of the patient medications if the patient has been eprescribed in the past by anyone. If this patient has been referred to us, please click the box labeled "Reconciled Medications", after confirming their medications with dosages. If the patient is uncertain of the dosage, or if prepopulating an established patient from our existing paper chart without dosages, just use the lowest dosage available.
7.
8.
Regarding asking questions about the ROS, I would prefer that we just ask from the following categories, unless anything else seems to make sense: "Constitutional", "Cardiovascular", "Respiratory", "Hematology/Oncology" "HENT", and "Integumentary" . IF A PATIENT REPORTS A CONSTITUTIONAL, CARDIOVASCULAR, OR RESPIRATORY COMPLAINT, PLEASE ADVISE THEM TO CALL THEIR PRIMARY MEDICAL DOCTOR IMMEDIATELY. PLEASE DOCUMENT THIS IN THE PATIENT COMMUNICATION TAB.
9.
We will need to collect the pharmacy information for that patient too. This can be done by opening the "eRx" button in the ocular medication list tab -‐-‐ I think.
10.
If a patient is called during prepping, please also check the "reminder" box in patient communication section of the summary page. ( We will probably have to mark this somewhere in NextGen as well.). This can be seen as an option in the drop down list, on the communications tab of the patient summary. It is labeled "Patient Reminder (MU Stage 1) -‐-‐ see below
11.
12.
Always "Lock Encounter" when you are done with the prepped visit, so that it does not show up in the list of incomplete charts that I need to review.
13.
A few basic principles for preparing charts in advance of clinic:
Guide to Prepping ChartsThursday, April 30, 2015 7:45 AM
We need to choose the proper appointment type, which is "prepped chart". If not, it will increase the risk of a federal penalty for not meeting "Meaningful Use" measures. Anytime we are documenting anything in the chart for a patient who has not yet had a visit utilizing EMR, we have to choose "prepped chart".
1.
We do not associate the "prepped chart" visit with a real clinic appointment. That means don't choose their actual appointment date. Choose the date that the chart is actually being prepped, if over the phone. If the chart is being prepped based on previous paper visit or based on referral documentation, choose the date from the papers as the "prepped chart" date.
2.
3.
Don't choose an actual appointment date from the list at the bottom. Consequently, when you click 'Save', you will get a pop-‐up message that says: "No appointment has been selected. Blah Blah Blah. Are you sure you want to continue?". Click "OK".
4.
No you are looking at the familiar chart for the patient. For prepping, only march along the bottom of the chart, filling out "Ocular Problem List", "Ocular Meds", and "PSFH/ROS"…. Do not fill out "HPI" in a prepped chart.
5.
6.
Remember, in ocular meds (or in system meds section of PSFH), always click "Load Dr. First Meds", because it will auto-‐populate all of the patient medications if the patient has been eprescribed in the past by anyone. If this patient has been referred to us, please click the box labeled "Reconciled Medications", after confirming their medications with dosages. If the patient is uncertain of the dosage, or if prepopulating an established patient from our existing paper chart without dosages, just use the lowest dosage available.
7.
8.
Regarding asking questions about the ROS, I would prefer that we just ask from the following categories, unless anything else seems to make sense: "Constitutional", "Cardiovascular", "Respiratory", "Hematology/Oncology" "HENT", and "Integumentary" . IF A PATIENT REPORTS A CONSTITUTIONAL, CARDIOVASCULAR, OR RESPIRATORY COMPLAINT, PLEASE ADVISE THEM TO CALL THEIR PRIMARY MEDICAL DOCTOR IMMEDIATELY. PLEASE DOCUMENT THIS IN THE PATIENT COMMUNICATION TAB.
9.
We will need to collect the pharmacy information for that patient too. This can be done by opening the "eRx" button in the ocular medication list tab -‐-‐ I think.
10.
If a patient is called during prepping, please also check the "reminder" box in patient communication section of the summary page. ( We will probably have to mark this somewhere in NextGen as well.). This can be seen as an option in the drop down list, on the communications tab of the patient summary. It is labeled "Patient Reminder (MU Stage 1) -‐-‐ see below
11.
12.
Always "Lock Encounter" when you are done with the prepped visit, so that it does not show up in the list of incomplete charts that I need to review.
13.
A few basic principles for preparing charts in advance of clinic:
Guide to Prepping ChartsThursday, April 30, 2015 7:45 AM