emr work flow

61
EMR Work Flow KNIGHTS Clinic at Grace Medical Home

Upload: odeda

Post on 25-Feb-2016

45 views

Category:

Documents


0 download

DESCRIPTION

EMR Work Flow. KNIGHTS Clinic at Grace Medical Home. Logging in for the FIRST time. Username and password- Username is first initial and last name with first initial and first letter of last name capitalized (ex. John Smith – JSmith ) Password: Temporary password is “password” - PowerPoint PPT Presentation

TRANSCRIPT

Page 1: EMR Work Flow

EMR Work FlowKNIGHTS Clinic at Grace Medical Home

Page 2: EMR Work Flow

Logging in for the FIRST time

Username and password- Username is first initial and last name with first initial and

first letter of last name capitalized (ex. John Smith – JSmith)Password:

Temporary password is “password”** you will be asked to change this eventually**

Open 3 tabs:Click on Run in the upper left and open:

ChartViewScheduleTracker

You will not have to do this step again!

Page 3: EMR Work Flow

To review patient historyGo to schedule, find your patient, right click and

select “Launch Chart”From there, choose health summary (upper left

side) and you can scroll through the categories

Page 4: EMR Work Flow

Once the patient has checked in by the front desk... Placing a patient in

a room When you are ready to bring the patient back - go to the

tracker, and move patient to the correct room (remember, you need to select the physician you are working with in order for the patient to pop up on the left “in the waiting room”)This is your first important time marker!!

Page 5: EMR Work Flow
Page 6: EMR Work Flow

Once patient is in the correct room, click on their name again on the tracking board and click “collect vitals” (this will open the patient’s chart)***this is your

second important time marker!!***

Page 7: EMR Work Flow

“Reminders” When first opening a patient chart click “Reminders” on the

tool bar Reminders will then appear on the side of the screen If a reminder is addressed during the visit it needs to be

removed manually by clicking the red “remove” sign When first opening a patient chart at the bottom of the

home screen will be a list of rules. Click “Run All” to refresh the list (NOT “Refresh”) These rules are important items that need to be addressed with

the pt during their visit When the rules are addressed and properly documented they

will automatically be removed from the list

Page 8: EMR Work Flow

Starting a New Doctor’s Note

To start your new Doctors Note- click on the piece of paper and select “Doctors Note”Select your

attending physician as “Health Care Professional” and yourself (student) as “Assistant”

Page 9: EMR Work Flow

Ok, I’ve seen the patient. Now what?

Take a few minutes to discuss, talk to Patient Education, then present to attending physician

***if you feel comfortable, begin filling out electronic document while speaking with attending physician***

The next step is to see the patient one last time with your attending

Page 10: EMR Work Flow

Seeing the patient with an attending

***REMEMBER- go back to tracker, right click on patient name and select “With Physician” ***this is your third

important time marker!!***

Confirm plan with the attending- including any labs, medication, or procedures that need to occur before the patient leaves **DO NOT ENTER ANY LABS

WITHOUT CONFIRMING WITH THE ATTENDING**

Page 11: EMR Work Flow

Filling out the Electronic Note

First, choose your CC (Chief Complaint)Once you have a chief complaint, you can now skip down to

the plan ** Remember to ALWAYS CHOOSE “Grace General Medical

Plan”From there, you can specify what needs to be done with your

patient. Once you have entered all information, the lab/pharmacy

etc can do their job so the patient can leave ASAP** don’t forget to enter patient education information—

patient education should give you the handouts they gave the patient so you can select the correct information—this is under the “plan” section of the document

Page 12: EMR Work Flow

Doctor’s Note- Chief Complaint

Page 13: EMR Work Flow

Doctor’s Note- Chief Complaint

Page 14: EMR Work Flow

Doctor’s Note- Chief Complaint

Page 15: EMR Work Flow

Doctor’s Note- Chief Complaint

Page 16: EMR Work Flow

Doctor’s Note- Chief Complaint

Page 17: EMR Work Flow

Doctor’s Note- Plan

Page 18: EMR Work Flow

Doctor’s Note- Plan

Page 19: EMR Work Flow

Doctor’s Note- Plan

Page 20: EMR Work Flow

Doctor’s Note- Plan

Page 21: EMR Work Flow

Doctor’s Note- Plan

Page 22: EMR Work Flow

Doctor’s Note- Plan

Page 23: EMR Work Flow

Doctor’s Note- Plan

Page 24: EMR Work Flow

Doctor’s Note- Plan

Page 25: EMR Work Flow

Filling out the Electronic Note

Now, go back and fill in the rest of your document Vitals, Physical Exam, ROS etc. ** remember, if patient has been here before, all

PMH/Meds/Allergies etc should be on the left hand side—**verify this information with the patient, add or delete as necessary

and make sure to click “Reviewed” for each box. This information can now be transferred over to your

document by using the small arrow tabs next to the abbreviated category names on the left hand side of your document- Click on the arrow and on the drop down box click add!

*** if you change anything on the left after adding to your document, remember to just click “Refresh” and your document will be updated.

Page 26: EMR Work Flow

Filling out the Electronic Note- Vitals

Page 27: EMR Work Flow

Health Summary-Allergies

Page 28: EMR Work Flow

Health Summary-Allergies

Page 29: EMR Work Flow

Health Summary-Allergies

Page 30: EMR Work Flow

Health Summary-Allergies

Page 31: EMR Work Flow

Health Summary- Medications

Page 32: EMR Work Flow

Health Summary- Medications

Page 33: EMR Work Flow

Health Summary- Medications

Page 34: EMR Work Flow

Health Summary- Medications

Page 35: EMR Work Flow

Adding Vitals and Items from the Health Summary

to the Doctors note

Page 36: EMR Work Flow

Doctor’s Note- HPI

Page 37: EMR Work Flow

Doctor’s Note- HPI

Page 38: EMR Work Flow

Doctor’s Note- HPI

Page 39: EMR Work Flow

Doctor’s Note- HPI

Page 40: EMR Work Flow

Doctor’s Note- ROS

Page 41: EMR Work Flow

Doctor’s Note- ROS

Page 42: EMR Work Flow

Doctor’s Note- ROS

Page 43: EMR Work Flow

Doctor’s Note- ROS

Page 44: EMR Work Flow

Doctor’s Note- Exam

Page 45: EMR Work Flow

Doctor’s Note- Exam

Page 46: EMR Work Flow

Doctor’s Note- Exam

Page 47: EMR Work Flow

Doctor’s Note- Exam

Page 48: EMR Work Flow

Doctor’s Note- Assessment

Page 49: EMR Work Flow

Doctor’s Note- Assessment

Page 50: EMR Work Flow

Doctor’s Note- Assessment

Page 51: EMR Work Flow

Doctor’s Note- Assessment

Page 52: EMR Work Flow

When can my patient leave?

After everything has been completed for your patient (labs, prescriptions, referrals) and instructions have been given to your patient—YOUR PATIENT CAN LEAVE! – even if you’re not done with your document.

** remember, our priority is to provide the best care possible in a reasonable amount of time

Page 53: EMR Work Flow

Do I have to ‘check out’ my patient?

When patient is cleared to leave—go to tracker, click on patient and select “check out”

***this is your fourth important time marker!!***

** don’t forget the check-out sheets on the back of the door fill out the information and give to your patient so they can check out

Page 54: EMR Work Flow

I think I’m done with my note. Now what?

** don’t forget the check-out sheets on the back of the door fill out the information and give to your patient so they can check out

Once happy with your document, tell the attending physician so they can review it—STUDENTS DO NOT NEED TO SIGN THE DOCUMENT-

The attending physician will take care of signing and closing the document.  

Remember, when logging out ALWAYS CLICK THE KEY SYMBOL.

Page 55: EMR Work Flow

For Physicians: Signing off the Note

Page 56: EMR Work Flow

For Physicians: Signing off the Note

Page 57: EMR Work Flow

For Physicians: Signing off the Note

Page 58: EMR Work Flow

For Physicians: Signing off the Note

Page 59: EMR Work Flow

Key Points to Remember…TRACKING

Pt. will be listed in waiting room, left click to assign them to a room “in room”

On tracking board left click on patient again and click “collect vitals” (this opens the pt’s chart)

Once you have completed filling out the chart click the gold key to log off

After you have collaborated with your attending and the attending is ready to enter the room go to tracking board again. Left click on the patient and click “physician provider start”

When is pt is ready to leave select “check out”

Page 60: EMR Work Flow

Key Points to Remember…CLINIC FLOW

Student pairs will interview patient and perform physical exam

Student pairs will review their findings and notify patient education to enter the room while presenting to their attending

Student pairs will discuss a plan with the attending physician and then see the patient again with the physician.

Student pairs will notify the lab if there are any labs to drawn

Student pairs will notify pharmacy if they plan on prescribing any medications

Page 61: EMR Work Flow

Thank You for Choosing to Volunteer with the

KNIGHTS Clinic at Grace Medical Home