Transcript EMR Work Flow SLM

EMR Work Flow
KNIGHTS Clinic at Grace Medical Home
Logging in for the FIRST time
 Username and password Username is first initial and last name with first initial and
first letter of last name capitalized (ex. John Smith –
JSmith)
 Password:
 Temporary password is “password”
 ** you will be asked to change this eventually**
 Open 3 tabs:
 Click on Run in the upper left and open:
 ChartView
 Schedule
 Tracker
 You will not have to do this step again!
To review patient history
 Go to schedule, find your patient, right click and select
“Launch Chart”
 From there, choose health summary (upper left side)
and you can scroll through the categories
Once the patient has checked in by the
front desk... Placing a patient in a room
 When you are ready to bring the patient back - go to the tracker, and
move patient to the correct room (remember, you need to select the
physician you are working with in order for the patient to pop up on
the left “in the waiting room”)
 This is your first important time marker!!
 Once patient is in the correct
room, click on their name
again on the tracking board
and click “collect vitals” (this
will open the patient’s chart)
 ***this is your second
important time
marker!!***
“Reminders”
 When first opening a patient chart click “Reminders” on the tool bar
 Reminders will then appear on the side of the screen
 If a reminder is addressed during the visit it needs to be removed
manually by clicking the red “remove” sign
 When first opening a patient chart at the bottom of the home screen
will be a list of rules. Click “Run All” to refresh the list (NOT “Refresh”)
 These rules are important items that need to be addressed with the pt
during their visit
 When the rules are addressed and properly documented they will
automatically be removed from the list
Starting a New Doctor’s Note
 To start your new Doctors
Note- click on the piece of
paper and select “Doctors
Note”
 Select your attending
physician as “Health
Care Professional”
and yourself (student)
as “Assistant”
Ok, I’ve seen the patient. Now
what?
 Take a few minutes to discuss, talk to Patient
Education, then present to attending physician
 ***if you feel comfortable, begin filling out electronic
document while speaking with attending physician***
 The next step is to see the patient one last time with
your attending
Seeing the patient with an
attending
 ***REMEMBER- go back to
tracker, right click on patient
name and select “With
Physician”
 ***this is your third
important time marker!!***
 Confirm plan with the
attending- including any labs,
medication, or procedures that
need to occur before the
patient leaves
 **DO NOT ENTER ANY
LABS WITHOUT
CONFIRMING WITH THE
ATTENDING**
Filling out the Electronic Note
 First, choose your CC (Chief Complaint)
 Once you have a chief complaint, you can now skip down to
the plan **
 Remember to ALWAYS CHOOSE “Grace General
Medical Plan”
 From there, you can specify what needs to be done with your
patient.
 Once you have entered all information, the lab/pharmacy
etc can do their job so the patient can leave ASAP
 ** don’t forget to enter patient education information—
patient education should give you the handouts they gave
the patient so you can select the correct information—this
is under the “plan” section of the document
Doctor’s Note- Chief
Complaint
Doctor’s Note- Chief
Complaint
Doctor’s Note- Chief
Complaint
Doctor’s Note- Chief
Complaint
Doctor’s Note- Chief
Complaint
Doctor’s Note- Plan
Doctor’s Note- Plan
Doctor’s Note- Plan
Doctor’s Note- Plan
Doctor’s Note- Plan
Doctor’s Note- Plan
Doctor’s Note- Plan
Doctor’s Note- Plan
Filling out the Electronic Note
 Now, go back and fill in the rest of your document Vitals,
Physical Exam, ROS etc.
 ** remember, if patient has been here before, all
PMH/Meds/Allergies etc should be on the left hand side—
 **verify this information with the patient, add or delete as
necessary and make sure to click “Reviewed” for each box.
 This information can now be transferred over to your
document by using the small arrow tabs next to the
abbreviated category names on the left hand side of your
document Click on the arrow and on the drop down box click add!
 *** if you change anything on the left after adding to your
document, remember to just click “Refresh” and your
document will be updated.
Filling out the Electronic NoteVitals
Health Summary-Allergies
Health Summary-Allergies
Health Summary-Allergies
Health Summary-Allergies
Health Summary- Medications
Health Summary- Medications
Health Summary- Medications
Health Summary- Medications
Adding Vitals and Items from
the Health Summary to the
Doctors note
Doctor’s Note- HPI
Doctor’s Note- HPI
Doctor’s Note- HPI
Doctor’s Note- HPI
Doctor’s Note- ROS
Doctor’s Note- ROS
Doctor’s Note- ROS
Doctor’s Note- ROS
Doctor’s Note- Exam
Doctor’s Note- Exam
Doctor’s Note- Exam
Doctor’s Note- Exam
Doctor’s Note- Assessment
Doctor’s Note- Assessment
Doctor’s Note- Assessment
Doctor’s Note- Assessment
When can my patient leave?
 After everything has been completed for your
patient (labs, prescriptions, referrals) and
instructions have been given to your patient—
YOUR PATIENT CAN LEAVE! – even if you’re not
done with your document.

** remember, our priority is to provide the best care
possible in a reasonable amount of time
Do I have to ‘check out’ my
patient?
 When patient is cleared to
leave—go to tracker, click
on patient and select
“check out”
 ***this is your fourth
important time marker!!***
 ** don’t forget the check-out
sheets on the back of the
door fill out the
information and give to your
patient so they can check
out
I think I’m done with my note.
Now what?
 ** don’t forget the check-out sheets on the back of the
door fill out the information and give to your patient
so they can check out
 Once happy with your document, tell the attending
physician so they can review it—STUDENTS DO NOT
NEED TO SIGN THE DOCUMENT-
 The attending physician will take care of signing and
closing the document.
 Remember, when logging out ALWAYS CLICK THE
KEY SYMBOL.
For Physicians: Signing off
the Note
For Physicians: Signing off
the Note
For Physicians: Signing off
the Note
For Physicians: Signing off
the Note
Key Points to Remember…
 TRACKING
 Pt. will be listed in waiting room, left click to assign them
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to a room “in room”
On tracking board left click on patient again and click
“collect vitals” (this opens the pt’s chart)
Once you have completed filling out the chart click the
gold key to log off
After you have collaborated with your attending and the
attending is ready to enter the room go to tracking board
again. Left click on the patient and click “physician
provider start”
When is pt is ready to leave select “check out”
Key Points to Remember…
 CLINIC FLOW
 Student pairs will interview patient and perform physical exam
 Student pairs will review their findings and notify patient
education to enter the room while presenting to their attending
 Student pairs will discuss a plan with the attending physician
and then see the patient again with the physician.
 Student pairs will notify the lab if there are any labs to drawn
 Student pairs will notify pharmacy if they plan on prescribing
any medications
Thank You for Choosing to
Volunteer with the KNIGHTS
Clinic at Grace Medical Home