guide to prepping charts - joseph walrath, md€¦ ·...

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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. Anytimewe 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. Choosethe 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. A few basic principles for preparing charts in advance of clinic: Guide to Prepping Charts Thursday, April 30,2015 7:45 AM

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Page 1: Guide to Prepping Charts - Joseph Walrath, MD€¦ · the#chartis#actually#being#prepped,#if#over#the#phone.##If#the#chartis#being# ... (MEDICAL(DOCTOR(IMMEDIATELY.PLEASE(DOCUMENT(THIS(IN(THE(PATIENTCOMMUNICATION(TAB

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

Page 2: Guide to Prepping Charts - Joseph Walrath, MD€¦ · the#chartis#actually#being#prepped,#if#over#the#phone.##If#the#chartis#being# ... (MEDICAL(DOCTOR(IMMEDIATELY.PLEASE(DOCUMENT(THIS(IN(THE(PATIENTCOMMUNICATION(TAB

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

Page 3: Guide to Prepping Charts - Joseph Walrath, MD€¦ · the#chartis#actually#being#prepped,#if#over#the#phone.##If#the#chartis#being# ... (MEDICAL(DOCTOR(IMMEDIATELY.PLEASE(DOCUMENT(THIS(IN(THE(PATIENTCOMMUNICATION(TAB

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