Electronic Health Records20

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Transcript Electronic Health Records20

Chapter 20
 Discharge a patient from the examination area
 Complete open orders
 Review the patient’s paperwork with the patient
 Send the patient to the payment collections desk
 Patient discharge workflow
 Out the door process
 Open orders
 Aftercare instructions
 When physician finishes Out the Door process, open orders (incomplete
orders) might need to be completed before discharging patient with
patient’s paperwork from medical facility
Even though physician is seeing another patient the clinical staff might need
to complete open orders in MedTrak
Patient Discharge Workflow step is important for these reasons:
Physician can focus on treating another patient without having to worry
about whether any orders are missed for this patient
Clinical staff do not need to wait for physician to come out of an exam
room to know what the physician wants them to do for the patient
Everyone in facility knows that everything will be done for a patient before
the patient is discharged from the facility
 The physician might have ordered a medication and if it was dispensed
medication the clinical staff will need to take medication off the shelf
record the lot number and give it to the patient
 If it was a prescription the clinical staff might need to obtain physician’s
signature on prescription before giving to patient
 If patient was in medical facility for an injury/illness the clinical staff will
need to give the patient his/her aftercare instructions
 Go to Clinic Status screen
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 Figure 20-1
 Place cursor in command field next to patient name click Open Orders
button to see orders that need to be completed for the patient
Open Orders screen reflects what the clinical staff must do
Go to procedure screens for first three questions then enter “x” in each of
answer fields enter MedTrak employee initials in Completed By answer
field-Figure 20-2
You can see answering each question and then clicking the Submit Answers
button saves time
Next screen to appear is procedure screen for Appliance utilized question
Do This! Pg. 249
 Figure 20-3
 Select appliance and enter “x”
 Entering “x” is equivalent of “1” in quantity field
 Click Submit button
 MedTrak records the selection and automatically advance to the next
procedure selection screen
Message appears at top of screen
Click Exit Screen button to go to next question screen in workflow for
Select the next option by typing “x” in quantity field next to the option
Figure 20-4
 After making selection click Submit button
 MedTrak records selection of option and automatically advances to next
question screen for Dispensed supplies question
 Select option by typing an “x” in quantity field next to option button
 Figure 20-5
 Click Submit button to record selection
 MedTrak automatically advances to next procedure screen and checks
two conditions (rules) to see if patient is ready to be discharged:
 Has the physician finished Out the Door process?
 Are all open orders complete?
 If met MedTrak automatically prints the patient’s Aftercare Instructions, Prescriptions, and
Visit Charges
 Workflow STATUS column may display IN Prtg (instructions Printing)
 Click Submit/Refresh button to refresh the screen which resets workflow STATUS to
 Figure 20-6
 ORDER column now displays DONE-indicating there were open orders which are now
 Workflow STATUS column displays Disch to indicate that paperwork for this patient
printed and is ready for review with patient
Who can now be discharged from the medical facility
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 To finish clinical portion of workflow clinical staff must:
 Print patient’s paperwork, aftercare instructions, prescription(unless )
charges for visit(patient’s responsibility visit only)
Retrieve dispensed medication(if ordered)
Get the provider’s signature on any prescription forms (if prescribed)
Return to room to se patient
Review aftercare instructions with patient
Review medications with patient both prescription and dispensed
Review charges with patient(patient responsibility visits only)
Instruct patient to pay at front desk(patient responsibility visits only)
Discharge patient from Clinic Status screen
 Place cursor in command field next to patient name and click Discharge button to display
Discharging screen-Figure 20-7
Enter your password in password entry field and click Submit button
If you have a global password just click Submit button
In real clinical setting clinical staff typically share computers so clinical staff will need to
enter his/her employee password on this screen
Click Submit button
Click Status screen refreshes with patient moved to reception area (payment collection
desk) for payment of services for the visit
Workflow Status is now Done
This notifies front desk person that charges for visit need to be reviewed with patient and
reminds them to collect any monies due at this time
Figure 20-8
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 You will need to print and turn in aftercare instructions , prescriptions,
visit charges documentation for patient that you completed in
electronic health records
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