Ambulatory

UHMGPsychGoldenbergWorkflow- Full Electronic Documentation

Prep Work:

All /
  • Review My Active Tasks for tasks that are assigned to you

Goldenberg /
  • Review Worklist tab for your incoming results and Rx refill requests. ‘Verify’ and/or ‘Authorize’ and task to clinicians. PRN
  • Review Tasklist /Worklist tab for physicians that you are covering. Sort by abnormals by clicking on the exclamation point (!) to review those results as needed. Create an addendum for results if you take action, but do not verify them so they remain in the ordering providers’ queue for review upon their return.
  • Ensure that all charges and notes have been completed for the prior days’ patients
  • Access Community Record – In the bottom right portion of this window, click the “Community” button to access community record to review patient documentation as needed

Patient Intake

Douglas Moore Resident /
  • If a resident wants Neal Goldenberg to see a patient they will send him a consult letter
  • In the consult letter header indicate the reason for the referral

Neal Goldenberg /
  • Review progress notes generated by Douglas Moore residents to determine whether or not to see certain patients
  • If you will see a certain patient, search for patient in aEMR and send “Referral Order Follow Up” task to the appointment schedule team task list and indicate that you will see that patient

Patient Visit:

NOTE: Bold items in tealitems appear on Clinical Summary for patient and should be completed by youbefore the patient leaves. The other items can be completed after the visit.
Douglas Moore 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”
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)
  • Chief Complaint–Enter appropriate CC. If chief complaint doesn’t appear in ACI, use “Visit for Other”
  • Start Office Note
  • Specialty: Psychiatry, Visit Type: Office Visits > Psychiatry Consultation Initial
  • Add / Complete OH Screening Form while in office note
  • Right Click Note Menu > Add SectionSelect ‘Screening’
  • Right Click ‘Screening’ > Add Form > Search for “Screening” and select option
  • Click on Save and Close to save changes to the note
  • Patient Location:Update patient indicator to “Room #”, and status to “Provider Ready”

Physician
Physician/
MDs only
. /
  • Patient checks in at front desk on Walker Floor
Front Desk will send email when patient is ready
  • Tasks –Review tasklist for the patient to ensure nothing is missed PRN
  • Info –Access ( i ) information button
Update the ‘Patient Care Team’ with your info if desired.
  • Update FYIPRN
  • Open Note – Click on note icon generated by the MA from daily schedule
Ensure attending provider name is selected in Note Owner Field
  • MU Chief Complaint – Must add Chief Complaint by ACI, if none applicable use “Visit for: Other.”
Continue to update in free text if needed.
  • MU Meds/Allergies – Reconcile the Current Meds and Allergies from the clinical desktop
  • MUSocial Hx (enter in smoking status for the patient). Enter in ACI history builder section. Choose from list of smoking favorites. (Only on patients older than 13 years of age)
  • Medical History Review
  • Active Problems - review and add if appropriate
  • Past Medical History - review and add if appropriate
  • Surgical History - review and add if appropriate
  • Family History - review and add if appropriate
  • HPI – Add additional narrative if necessary.
  • ROS – Verify RN entry and use noteform, type or use Dragon to input information to update if needed
  • Active Problems – Review and update.A designation of one active problem or no active problems must be entered to meet MU.
  • Histories – Review PMH and activate any current problems (change status to > active), Collect/verify PSH, Fam Hx
  • Vitals – Review as necessary
  • Reference Documentation (PRN) – Check boxin EMR Reference Documentation for visits requiring additional paper documentation (Patient Intake Form)
Patient intake form if going to be scanned into aEMR.
Additional Scales and Forms that are on paper will be scanned in.
  • PE – Use noteform, type, or Dragon to input information
  • Results/Data – Review labs. Pull in previous results using the “Advanced result citation” feature PRN
  • Drawings – All drawings completed by patients must be stored in shadow chart or in outside storage. Can’t be scanned into aEMR.
  • MUDiagnoses/Problems – Select which active problems you are going to assess by checking a green check on the notepad in front of the diagnosis and add new ones if necessary. Open Care guides/Qsets from this area to add orders. ***
  • MU Orders – Order Rx, Labs, DI, Procedures, Referrals, Education PRN
  • Can order using problem based orders--Care guides
  • Referrals entered via the Orders section
Routine for central scheduling* (Most common way to schedule/defaulted)
Use Stat for secretary scheduling
Specify referral reason by selecting second radio button and free text reason for referral.
  • MU Patient Instructions – Indicate how patient education was given via the ACI screen
  • Provider Impressions – Enter notes specific to your care that are for your reference PRN. These will not display on the clinical summary.
You can also dictate a provider’s name you want a referring consult letter to be sent.
  • Patient Discussion/Summary – Enter information you want to share with the patient on Clinical Summary.
  • Follow-up visits - Notate when you would like the patient to return for their follow up visit. ***
  • Indicate follow-up in patient discussion summary. Can be entered in by typing, dictation, or dragon template
  • Consult Letter/Referral Letter
Send consult/referral letter electronically by first checking the Referral-Consult Letter box and then clicking the Carbon-Copy button
Select the resident who sent the intial referral letter.
This will drop to all residents in that particular group.
  • Sign/Finalize Note
  • Save and Close – Use the Save and Close button to save your changes
  • Status – Use ‘Orders Pending’ patient status to alert RN that her assistance is needed or change status to ‘Visit Complete’PRN
  • Printing – Requisitions or controlled medications will print upon saving; Also, print any education materials and give to patient PRN
  • MUClinical Summary – Print and send patient to checkout. Front desk will hand to patient.
NOTE: You are able to edit the clinical summary before printing by clicking on ‘Edit Clinical Summary’ and selecting certain sections that you want displayed in this document
  • If provider needs to write secure comments or notes, the provider will open second encounter/note.
Create a Psych Communication Note
Physician
Goldenberg /
  • Sign – Press the Sign button to sign and finalize the visit note
  • Charges: Fill out paper charge ticket

Patient Leaving
Billing /
  • Can only bill case if patient is seen by MD provider

Patient Left - Patient Encounter Complete

Between Patients:

End of Day:

All /
  • Review My Active Tasks for tasks that are assigned to you

Secretaries /
  • Print out daily Rx report from task list for physician to sign. Scan signed document into file cabinet in Scan.
  • Check the Print queue for successfully eRx/faxed Rxs
  • Send referral/consult letters to associated provider on account.
  • Scan any additional documents that the provider has flagged on chart.

Goldenberg /
  • Review Worklist tab for your incoming results and Rx refill requests. ‘Verify’ and/or ‘Authorize’ and task to clinicians as needed.
  • Review Worklist tab for physicians that you are covering. Sort by abnormal to review those results as needed. Create an addendum for results if you take action, but do not verify them so they remain in the ordering providers’ queue for review upon their return.PRN
  • Covering Providers will only look at urgent items on an out of office provider’s work list. Filter urgent by selecting the (!).
  • Physicians will utilize verify option on any outstanding work list items. Nurse and covering provider will only annotate on open work list items.
  • Document Telephone Encounters
  • Open Note->Communication->Psych Patient Communication
  • Sign Note if no additional follow-up is needed.
**If telephone encounter is not pre-scheduled; note will be created and an encounter will be linked retrospectively once an appointment is created in Athena.**

MU refers to the items that are important for Meaningful Use stage 1 requirement. Please refer to the meaningful use handout for additional information about the specific guidelines and percentages required.

Published date 6.3.2013