Electronic Health Records9

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Transcript Electronic Health Records9

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
Put the chart in the rack for the physician
Reason(s) for visiting
Medical history
Vital signs
Real reason for visit
Presenting problem
Answer field
Expanded answer
Standard answers
Stores responses
Normal answers
On-line chart
Key Concepts
Medical office workflow
• 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
• 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
Checking Room
• 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
• Do This! Pg. 124
Moving A Patient To A
• 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
• 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
• 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
• 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
• 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
• 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
• Normal answers are a subset of standard questions available for a
• 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 NONEmeaning 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
• 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
• 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 answersFigure 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
• 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
• 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