Transcript Out the Door (Overview)

Out the Door
(Overview)
Chapter 12
Objective
 Understand
screen
the Visit Documentation
Key Concepts
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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
Out The Door
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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
Out The Door
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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
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
Presenting Targeted
Information
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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
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.”
Two-Minute Drill
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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
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
Figure 12-1
Orders
 Enables
physician to:
 Place additional orders using problemfocused 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
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
Diagnosis
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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
History And Exam
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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
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
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
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
Done Or Not Done
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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”