Transcript Aftercare Instructions (Physician)

Chapter 18
• Select patient aftercare instructions
• Modify patient aftercare instructions
• Create patient aftercare instructions
•
•
•
•
•
•
•
•
•
•
•
•
•
Aftercare instructions
Important points to remember
What to be concerned about
Medications
Work status
Work restrictions
Follow-up
Assessment and plan of care
Summation
Case closed
Standard instructions
Modifiable instructions
Specific instructions
• Once physician finishes placing orders, diagnosing, answering
history, exam questions next step in workflow is aftercare
instructions for patient to take home
• Problem-focused patient aftercare instructions automatically
and electronically generate and indicate care suggestions in
real time based on the patient’s problem list, which complies
with Meaningful Use Core Objective 11
• Aftercare instructions inform the patient as to what they can do,
activities patient should limit, what do to for self care after patient
leaves facility
• They also inform patient how to self treat, take prescribed
medications and when to return to medical facility
• Workers’ compensation patients will specify whether patient can work
without restrictions, with restrictions specified by physician, or
incapable of working at this time
MedTrak will send emails, faxes to employers with works status of
employee’s condition. MedTrak also has a real time employer portal for
employers to review their employee’s work related health care
information over the internet
• Important Points to Remember-instructions about what patient
should/shouldn’t do to self treat injury/illness
• What to be Concerned About-instructions to inform patient
about what to do if condition worsens
• Medications-instructions about whether or not patient should
continue/stop medications that they were taking previously
• Work Status-physician’s recommendation about whether patient
should/shouldn’t return to work or if there are work-related
restrictions
• Work Restrictions-instructions on what patient is encourage to
do, should limit doing, not do while at work
• Assessment and Plan of Care-physician’s assessment of patient’s
condition and detailed plan for treatment
• Summation-physician’s opinion of patient’s present condition
• Case Closed-physician uses this section to close workers’
compensation cases
• Standard-wording for instruction is from MedTrak library of
instructions
• Modifiable-a specific word/words in instruction, marked with
brackets(< >) on either side can be changed
• Specific-physician types in (or uses voice recognition) to create
instructions that are specific to patient
• Place cursor in Instructions field on Visit Documentation screen
(Figure 18-1) Click Instructions button to access first screen of
patient instructions
• Do This! Pg. 224 & 225
• On Instructions/Important Points to Remember screen, select the
following MedTrak standard instructions by clicking the
checkboxes:
• Reduce activity
• Left pain be the guide
• Rest and Limit Use
•
ankle
• Click Submit Selections button again to advance to next screen
of instructions. MedTrak moves to second screen since this section
is comprised of several screens of instruction choices
• Do This! Pg. 226
• On second Instructions/Important Points to Remember screen-select the
following instructions by clicking on checkbox:
• Ice-Ankle
• Appliances-Left Ankle Appliance-Wear at all times
• Appliances-Left Ankle Appliance-Remove to bathe
• Click Submit Selections button to accept selections
• Screen refreshes with selected instructions in black
• (Figure 18-3)
• Click Submit Selections button again to advance to next screen of instructions
• MedTrak moves to third screen(Figure 18-4)
• You do not want to select instructions on this screen so click Submit Selections
button again to advance to Instructions/Medications screen
• Do This! Pg. 228
• If patient is not currently taking medications do not select any of
the Medications Instructions…if they are look for their current
medication and check this (Figure 18-5)
• If patient is already taking prescription or over-counter
medications, instruct the patient as to whether the patient should
continue or discontinue taking his/her current medications given
the patient’s present condition. This is especially important when
prescribing any additional medications for the patient
• Click Submit Selections button to advance to the
Instructions/Work Status screen
• Do This! Pg. 229
• On Instructions/Work Status screen select the following
instruction by clicking on the checkbox:
• RETURN TO MODIFIED work duties <today>
• Click Submit Selections button to accept the selection
• Work Status screen refreshes with selected instruction in black
(Figure 18-6)
• Click Submit Selections button to advance to Instructions/Work
Restrictions screen
• Do This! Pg. 230
• On Instructions/Work Restrictions screen select the following by clicking on
checkbox: (Figure 18-7)
• We Encourage the following-<Specific Instruction>
• Click specific instruction button to right of instruction
• Next screen is Specific Instruction screen for Work/Restrictions/We Encourage
the following instruction
• Figure 18-8
• Type or use voice recognition software to enter the following instruction: “Limit
walking and standing while at work. Try to do sit down work only”
• Click Submit Instruction button
• Instructions/Work Restrictions screen returns with specific instruction appearing
under the instruction(Figure 18-9)
• Click Submit Selections button to advance to Instructions/Follow-Up screen
• Do This! Pg. 232
• Instructions/Follow-Up screen select following instructions by clicking
the checkbox:
• Return for next visit-<Specific Instructions>
• Click specific instruction button to right of instruction
• Next screen is Specific Instruction screen for Return for next
visit/Follow-Up (Figure 18-10)
• Type or use voice recognition software to enter “Call for another
appointment after your orthopedic visit”
• Click Submit Instruction button-Instructions/Follow-Up screen returns
with specific instruction now appearing under instruction(Figure 1811)
• Click Submit Selections button to advance to Instructions/Assessment
and Plan of Care Screen
• Do This! 234
• On Instructions/Assessment and Plan of Care screen select the following by
clicking checkbox:
• Additional Comments for Plan-Discussion of treatment options/contingencies: < >
• Click Specific Instruction button to right of instruction
• Next screen is specific instruction screen for Assessment and Plan of Care (Figure
18-12)
• Type or use voice recognition software to enter “Discussed with Mr. Baker my
initial findings of an unspecified internal derangement of left ankle, and the
need for him to see an orthopedic surgeon as soon as possible.”
• Click Submit Instruction button-Instructions/Assessment and Plan of Care screen
returns with specific instruction appearing under the instruction (Figure 18-13)
• Click Submit Selections button to advance to Instructions/Summation screen
• Do This! Pg. 235
• Click checkbox for Condition on discharge: <Good> in Summation
section type “fair” in modifiable instruction field to right of
instruction-click Submit Selections button
• When there is modifiable instruction field to right of instruction
brackets on either side of word/group of words designate
modifiable part of instruction
• If more than 10 characters are needed for modification of instruction
click specific instruction button to right of instruction
• Whatever is types in modifiable instruction field or on specific
instruction screen replaces word(s) inside brackets
• Instructions/Summation screen refreshes with word fair under
instruction(Figure 18-14)
• Do This! Pg. 238
• After finishing selecting, modifying and creating specific patient
aftercare instructions click Submit Selections button again to display
Instructions/Overview screen (Figure 18-15)
• Instructions/Overview screens displayed selected information in black
• If you review and decide to modify instruction in a section click green
cross to left of section name to access selection screen for that section
of aftercare instructions
• Click Page Down button to scroll down to see next
Instructions/Overview screen(Figure 18-16)
• Review Instructions/Overview screen click EXIT SCREEN button to
return to Visit Documentation screen which displays a message that
“Instructions have been marked.” (Figure 18-17)
• Do This! Pg. 238
• You will need to print and turn in Mr. Baker’s aftercare
instructions that you documented in the electronic health record
• Do This! Pg. 239