Transcript Resident to Attending Workflow

OB Physician Documentation
End User Education
Agenda
1. Brief Intro to Physician Documentation (PDOC)
2. Features/Benefits
3. Review list of OB Documents
4. How to Document in PDOC
5. Signing Workflow
a.
b.
Resident to Attending
Medical Student to Resident to Attending
6. Sign Queue
Why PDOC?
Features
 Automatically imports data from Nursing
Assessments
 Continuously updates with latest lab results
 Integrates with Home Medications, Allergies and
Problems List
 Documents can be shared among several users
Why PDOC?
Benefits
 Real-time documentation accessible in EMR
 Improves efficiency of documentation
process
 Reduces the occurrence of conflicting
information
 Includes ICD-10 Specificity to maximize
billing
List of OB Documents
Accessing PDOC
Click “Document” button within the Patient Chart.
Opening a New Document
Click “New” and select a document from the Document List.
Document Sections
Documents are organized into sections to simplify navigation.
Home Meds/Allergies
Automatically pulls in Home Medications and Allergies if previously documented.
Free Text Boxes
Click the drop down arrow to enter free text box. Can be used for typing or Dragon.
Review of Systems
Responses for symptoms are either “present” or “not present”.
Left Mouse Click
• Circles the response
• Indicates symptom
is present
Right Mouse Click
• Slash thru response
• Indicates symptom
is not present
Exam Normals
Click the “N” to automatically default the exam normals, or select responses on your own.
Instance Queries
Click the drop down arrow to select the instance. Associated questions populate.
Results Diagram
Lab results will populate the diagrams within the document in real time.
Patient Problems
Adding Patient Problems within PDOC will update Problem List.
You are able to document an assessment and plan for each problem.
1. Click Drop down arrow
2. Type in search field to find problem.
Problem w/ Qualifiers
Certain problems will include qualifier questions to be answered for increased specificity.
Sign Routine
Click “View/Save” to enter Sign Routine. Enter your pin to sign the document.
Add additional providers if appropriate
Additional
Providers
Enter Pin
Resident to Attending Workflow
Resident/PA
Initiates the
patient note
Completes
the patient
note
Assigns
Attending for
co-signature
E-Signs Note
(ISigned)
Locates
Resident
note in sign
queue.
Edits
note/adds
Attending
Attestation
E-Signs Note
(Signed)
Attending
Locates
Resident
note in
patient chart
OR
Medical
Student
Workflow
Student
Initiates the
patient note
Completes
the patient
note
Assigns
Resident for
co-signature
E-Signs Note
(ISigned)
Locates
Student note
in patient
chart
Locates
Student note
in sign queue
Edits
note/adds
Attending for
co-signature
E-Signs Note
(ISigned)
Locates
Resident
note in sign
queue
Edits
note/adds
Attending
Attestation
E-Signs Note
(Signed)
Resident
Attending
OR
Locates
Resident
note in
patient chart
OR
Sign Queue
Documents in a draft status, or requiring co-signature will be in your sign queue.
Select the documents you would like to sign and click “View & Sign”.
Reason Column
Blank = your report
Cosign = you’ve been
added as a cosigner