Ambulatory

UHMG Douglas Moore Resident Clinic Workflow- Full Electronic Documentation

Patient Visit:

Chart Prep – Before Patient Arrives in the Office
Front Desk /
  • For same day, add-on appointments:
  • Under patient info ( i ) - Click the “Check Eligibility” button in the Rx Benefit plan section
  • Review Tasklist -
  • My Active Tasks
  • Follow My Health – for appointment requests

MA /Nurse
**Nurse Only /
  • Scanning – Ensure that the prior day’s scanning is up to date
  • Backfill - Enter patient past history as available for patients on the day’s schedule (PRN)
  • Pull patient charts up to 3 days prior to scheduled visits and place in cart in Med Records room
  • Print schedule by Provider (Resident, Urgent Care, Nurse schedule)
  • Review Tasklist –
  • My Active Tasks (Telephone calls, other tasks)
  • **Med/Imm – medications / immunizations that need to be documented (ie. NDC, Lot, Dose)
  • **Follow My Health – for Medication Refills or Medical Question

Resident /
  • Review Tasklist (if applicable) –
  • My Active Tasks (Telephone calls, incomplete notes, etc.)
  • Review Worklist(if applicable) –
  • Order Results Management - ‘Verify’ lab and radiology results coming from UH and task to clinician as necessary.

Patient Arrives in the Office – Check-In
Front Desk /
  • Arrive patient in Athena and complete all current tasks done in Athena
  • Info – Access ( i ) information button
  • Update FYIand Chart Alerts as needed (PRN)
  • Enter patient preferred communication
  • Set clinical summary to ‘print’
  • Update/Verifyretail and mail order pharmacy Information
  • Update/Review Patient Care Team
  • Save changes
  • Patient Location:Update patient indicator to “Waiting Room”, and status to “MA Ready”

Triaging the Patient - Clinical Intake
MA /
  • Info – Access ( i ) information button
  • Review/AddFYIand Chart Alerts as needed (PRN)
  • Collect Advance Directivesand scan into Ambulatory Scan(PRN)
  • MU Transition of Care – Determine if patient qualifies for transition of care (TC)
  • MU Vitals – Weigh and room patient, collect vital signs and enter in UHCare Ambulatory, (MU vitals include height, weight, BMI, and BP 3yrs)
  • MUAllergies – Enter the patient’s allergies or an indication of “No known drug allergies”
  • Chief Complaint–Enter appropriate CC. If chief complaint doesn’t appear in ACI, use “Visit for Other”
  • Start the Office Note:
  • Location: Specialty > Internal Medicine, Visit Type > Office Visit
  • Add / Complete OH Screening Form while in Office Note
  • Right Click Note Menu > Add Section > Select Screening, > Right Click Screening > Add form
  • Save and Close the note
  • Patient Location:Update patient indicator to “Room #”, and status to “Provider Ready”

Resident - Before Entering Patient Room
Resident /
  • Info – Access (i) information button
  • Read or update FYI notes and Chart Alerts (PRN)
  • MUTransition of Care - verify if patient has seen another provider since last visit
  • Open Note –On daily schedule, click on the office note icon next to the patient appointment
  • Review Chart – The Chart Viewer tab displays electronic and scanned files for the patient

Resident Sees the Patient and Completes Documentation
NOTE:Bolditems in tealitems appear on Clinical Summary for patient and should be completed before the patient leaves. The other items can be completed after the visit.
MU refers to Meaningful Use stage 1 requirements. Please refer to the meaningful use handout for additional info.
Resident /
  • MU Current Medications – Review the patient’s current medications, addressing any “Unverified” medications brought into the patient’s chart from the Rx Eligibility Check
  • Verify Add meds patient currently taking
  • Order D/C meds that patient is no longer taking
  • If the medication is not listed, add the medication from the History Builder > Med Hx tab
  • If patient not taking any medications, record “No reported medications.
  • MU Meds/Allergies – Reconcile Meds/Allergies from tabs along top of Note Authoring Window
  • MU Chief Complaint –If “Visit for Other” was used, use the free text box to elaborate on visit reason
  • HPI – Free text History of Present Illness information(Free Text Only)
  • ROS – Free text or right click ROS from note menu to choose Complete male/female form
  • Note: Do not use “All Normal” button when ROS formis selected
  • MUActive Problems – Review and update as necessary
  • Record/Verify Histories (PRN) –Record/verify the patient’s past medical, surgical, and family history.
  • MU Social Hx –Record/verify patient’s tobacco history
  • MU Vitals – Review and add additional vitals as necessary or free text notes (ie. Patient refusal)
  • Physical Exam – Type or use point and click forms to input information
  • Results Data (PRN) – Review IO labs as necessary and free text results of other labs as needed.
  • Advanced Result Citation - right click within the box in the note to include any radiology or lab results that have been received via a UH interface into the Ambulatory EMR.
  • Procedure Note (PRN) – Type or use point and click forms to input information
  • Diagnoses/Problems – Select which active problems you are going to assess and add new ones if necessary. Open CareGuides/Qsets from this area to add orders (can add Pt instructions as needed).
  • MUPatient Education– Open Careguides/Qsets from this area based on diagnosis. Order from the “Instructions” section for meaningful use credit
  • Note:More than 10% of all unique patients must receive education resources from UHCare
  • Orders – “All” orders entered by a Resident require the Attending Physician be selected in the “Supervised by” field except for Medications, Referrals, Follow-Ups, Patient Instructions.
  • Select“New” button to place new orders.
  • Rx – Add any NEW prescriptions from this tab (refills should be handled from the patient’s medication list so that the medication is not duplicated).
  • Immunizations – Provider will order, Nurse will prep and record administration of vaccine
  • Labs/Procedures and Imaging – Add any labs, procedures,or radiology
  • Labs – When collected in-offce and sent to outside lab to test, choose “Lab Services – To Be Collected”
  • Imaging orders – select “non-interfaced” when done at non-UH facilities
  • FU/Ref – If a patient needs a referral, search by specialty to order a referral. Choose “Routine” for referral line to schedule with patient, “Stat” if Front Desk schedules
  • MU Patient Instructions – Check off instructions that will print on the clinical summary
  • Provider Impressions (PRN) – Assessment / plan for patient.“Not” included in Clinical Summary.
  • Patient Discussion/Summary – information to share with the patient on the Clinical Summary
  • MU Print the Clinical Summary – when items in the office note marked with an asterick are complete
  • Sign the Note – when all documentation by provider and clinical staff is complete
  • Co-sign task – Select the appropriate attending physician from the drop down menu
  • Note: Attending Provider will open note from task list, document impressions, and sign note to finalize
  • Reset Patient location and update status to “Visit Complete”or “Nurse Ready”if orders pending

Physician - Leaves Patient Room
Resident /
  • Inform Nurse of any additional orders that need to be done(PRN)
  • Collect Clinical Summary, requisitions, education materials from printer and deliver to patient
  • Complete remaining documentation HPI, ROS, Exam, Procedures (as time permits)

Front Desk/
MA/Nurse /
  • Important: Review task list to ensure nothing is missed

Front Desk / Check-Out /
  • Schedule lab and/or follow-up appointment with patient (PRN)

Between Patients
All /
  • Review “My Active Tasks” for tasks that are assigned to you

Front Desk / MA / Nurse /
  • Call Processing – Patient calls should be documented via the Call Processing section, tasked to the appropriate person, saved to telephone note, then closed out via My Active Tasks
  • Review task and work lists.
  • Follow My Health tasks – FMH Appt Requests(Front Desk)

MA / Nurse
**Nurse only /
  • Paper Non-UH Results – Scan paper documents that are signed off by the provider (non-UH results, etc). ‘Complete’ the order in UHCare as necessary.
  • Review Tasklist –
  • My Active Tasks (Telephone calls, other tasks)
  • **Med/Imm (Incoming refill requests, inform provider of refills that need their attention)
  • **Follow My Health – for Medication Refills or Medical Question

Resident /
  • Finish Notes/Charges - Complete unfinished documentation and submit charges on paper
  • Review Tasklist – My Active Tasks (med renewal, telephone calls, scanned documents, incomplete notes).
  • Review Worklist – Tasks typically done during patient visit
  • Medication Authorization
  • Order Results Management - ‘QVerify’ lab and radiology results coming from UH or task to nurse if follow up is required (see “additional workflow tasks” section below).

End of Day:

Resident /
  • Print and sign Daily Prescription (Rx) report from task list
  • Leave for MA to Scansigned document into Ambulatory Scan file cabinet

Additional Workflow Tasks:

When UH Results Require Additional Follow Up
Resident / If resident determines incoming UH Lab/Rad results require additionalfollow-up to be done by staff, he/she can annotate instructions to be communicated to patient directly on the result and task the result to appropriate staff member
  • From worklist, select the result, choose annotate to document instructions for staff member
  • Next, right click on the result to be tasked, choose the “task option from menu
  • When task window opens, select the staff member for the “Assign To” and confirm Task selected is “Go to Result”

  • QVerify the result to sign off on the results and remove it from your worklist

Nurse /
  • Review My Active Tasks for result follow-up actions that the resident has assigned to you
  • Double click on task and result will open
  • Review doctor’s annotation, and complete the needed follow-up
  • Annotate completion of follow-up on the result
  • From your tasklist, select “Done” for the result item to remove it from your active tasks

Nurse Only Visit Notes
Nurse /
  • As with Athena, there will be a Nurse Visit patient schedule
  • For Nurse Only visits that require documentation, choose appropriate Nurse Visit Note:
  • Location: Specialty > Internal Medicine, Owner > “Nurse name,” Visit Type > Nursing Visits
  • Nurse Note – Use when a Provider needs to finalize the note. Will generate a co-sign Note task to be sent to selected Provider when note is signed by the Nurse
  • Nurse Note (Per Protocol) – Use when Provider does not need to finalize the note