Greenway First Care Clinics

Transcription

1 Greenway First Care Clinics Topics include: Add an Order (Plan) pg 41 updated Add Assessment (Diagnosis) pg 40 updated Document a TB Skin Test Documenting Influenza Documenting Injections Flow Sheets Lab Order Requisition Open and Document a Task Orders Tracking Workflow Medication Adjustments Nurse Workflow Order Created by Somebody other than a Provider

2 Create a new Procedure Note. Documenting Influenza Immunization Select Influenza template: Located in First Care Templates - Injections

3 Document the Note section of the template. The assessment section will have the DX code Flur Vaccine checked by default. Adding the Order/Change In the plan section, select the appropriate immunization order. o Influenza Virus Vaccine (90658) for everyone except Medicare patients. If Medicare patient, select the one labeled Medicare (Q2038) o Click SAVE (Hold Charges)

4 Documenting the Injection After saving, click View/Edit Orders and choose the influenza vaccine order. The Immunization Dose window will appear Fill out the fields prompted. This will automatically populate the Immunization Flowsheet. When done, click SAVE. You will be taken to the order details page. Change the order status to Reviewed.

5 Documenting a TB Skin Test 1. Open a new Procedure Note 2. Select Template TB Skin Test Template Located in user First Care Templates Navigate to Note section and fill out the information. The Assessment will automatically have the DX in it, The Plan section has patient instructions to come back in two days and the order will automatically be checked. Save the note Save (Hold Charges) Patient returns 2 days later 1. Open the Procedure Note made during the previous visit. 2. Click View/Edit Orders Under Specific Assessment click the appropriate result. If the result is not listed, click (edit options) and add the result. Change the status to Reviewed then Save & Close the order. 3. Navigate to the Plan section of the note. In the Correspondence section you will see a letter title TB Skin Patient Letter. Click (Create Note). Fill out the information on this letter. Print and give to patient. Save & Sign the note.

6 TB Skin Test 1. Open a Procedure Note (With screen shots) 2. Select Template TB Skin Test Template Located in user First Care Templates Navigate to Note section and fill out the information. The Assessment will automatically have the DX checked. The Plan section has patient instructions to come back in 2 days and the order will automatically be checked. Save the note Save (Hold Charges)

7 Patient returns 2 days later Open the Procedure Note made during the previous visit. Click View/Edit Orders Under Specific Assessment click the appropriate result. If the result is not listed, click edit options and add the result. Change the status to Reviewed then Save & Close the order.

8 Navigate to the Plan section of the note. In the Correspondence section you will see a letter title TB Skin Patient Letter. Click Create Note Fill out the information on this letter. Print and give to patient. Save & Sign the note.

9

10 Injections In Patient Chart Progress Note (or a procedure note) If done in a progress note physician s name will show under select physician. If procedure note the physician s name has to be added. Plan Type in ordered injection example Decadron 4mg and enter an Administration Order as well ( See below )

11 Select ordering physician, Bill shows 1 mg change the 1 to a 4 so the patient is charged 4 mg Click Save (Hold Charges) Click View/Edit Orders Document the Injection

12 Under Ordered change status to Reviewed Click Save & Close

13 Add an Order (Plan) revised Lab X-Ray Add order by searching order name or selecting in template. Choose order in Greenway that corresponds to order in Meditech. Add order by searching order name or selecting in template. Mark order pending and in Notes Option type: sent to SBRMC for overread. Pg 41

14 Add Assessment (Diagnosis) revised Pg 40

15 Lab Order Requisition Destination: Change none to printer Check all in-house labs, then Print Un-check in-house, Check out going labs Then click Map All DX Click Add instructions and type: drawn by Time Click include digital Signature Click Save ; Click Submit Click Print, OK See example on Next Page

16

17 Meditech Ordering *Enter/Edit outreach requisition (Must all be done in CAPS) Type: New DHG Stadium (location) Enter ordering doctor (example: JKOSINSKI, CPECK, etc.) Type: SS# (hit cancel if a pop-up comes up) Name (last, first, middle intial) DOB Sex Next page (orders) Type: T tab N - tab Tech name, tab to orders Type first order in, then SCAN requisition barcode; continue typing all in house orders and SAVE Cancel to go back to main page for results

18 Meditech Results *Result Entry (Must all be done in CAPS) Type in patients name (Last, First) --hit enter Enter all results, commenting at end of each test --Comments --F5 --PERFS, choose First Care Stadium (or your location) --Key in tech initials SAVE SAVE Cancel to return to home screen To Print Lab inquiry Space click enter OK OK

19 Flow Sheets Update Flow Sheets from the Face sheet. Every one must have the PQRS and Health Maintenance Flow Sheet. These must be kept up to date. Other Flow Sheets are to be added according to need, example if the patient is on Coumadin. The Coumadin Flow Sheet must be added and kept up to date.

20 Open and Document a Task Open task Click comment Type in comment Save and return Create document Open misc note Document Save and sign then complete the task

21 Nurse Workflow 1. Go to Patient List 2. Click on patient s name from the Patient List to navigate to the patient s chart. 3. Once you are on the Facesheet, update medications, allergies, and all history sections pertinent to visit. 4. After entering all Facesheet information, select the CREATE NOTE option on the action bar (dark bar on the left). The blue options box will open and allow you to select what type of note you want. Select appropriate note, PROGRESS NOTE for sick visit or follow-up, H&P NOTE for new patient visit, PROCEDURE NOTE for procedures. 5. This will open to the Chief Complaint section. Go to the Wizard icon (or Sketch Pad) and manually enter in the CC. (Usually can go to First Care Templates, but sometimes it depends on who it is. Some physicians have their own Templates). 6. Move to PFSH on the dark side. Next to ALL PFSH, select B for basic display of history or C for comprehensive display of history. 7. Move to Vitals section, go to the Wizard in the upper right hand corner and add Vitals. 8. If you performed a Bladder Scan, enter under the In Office Procedure section. 9. Save & Hold Note 10. Click on the Patient Tracking icon in the upper right hand corner and change Patient Tracking for Status & Area. 11. Close Note 12. Close chart

22 Order s Created by Somebody Other Than a Provider 1. Navigate to patient s Chart 2. Click on Create Note on the left side action bar 3. Choose and Order s Note 4. Select Template 5. Work through sections of the note 6. When the note is complete you will take a Save & Sign action on the left action bar. 7. Route Document on the left action bar to the provider for a Co-Signature. a. Make sure when routing a document that the Reason is changed to Route for Co-Signature (this make it much more efficient for the provider to handle on their end)

23 Orders Tracking Workflow Providers: 1. From the Desktop go to the Chart Action Bar and Click on Orders 2. Make sure the filter is set to Returned 3. Click View/Edit on the order 4. View the Imported - Document (test results) 5. Sign off on the Result at the bottom of page. 6. Click the General Assessment: N/A, Normal, Abnormal 7. Click on Specific Assessment (If necessary) 8. Enter Additional Comments (If necessary) 9. On the top of the Order click on Follow-Up to create follow up tasks 10. Click the F/U Assessment: Unnecessary, Required, Performed 11. Click on the F/U Tasks 12. Select individual to perform follow up task 13. Add Additional Comments if necessary 14. Change status from RETURNED to REVIEWED at the top of the screen. 15. Save and close To create the assessment and follow-up option click on EDIT OPTIONS. This list is per CPT code and is system wide.

24 Orders Tracking Workflow- Continued Clinical Staff: 1. Click on Task List either in top of tool bar (this will allow you to minimize the task list) or in the left (dark side) 2. Click on the task to be completed 3. Click Open Order on right hand side. 4. The page will open to the Result page click on imported document to view the result and the MD s assessment. 5. Click on Follow-Up, read the task assigned and then make comments by clicking on the edit entry and typing in the box.(i.e., phoned pt, left message, etc) 6. Save and close. When clicking save and close it will stamp your name and the date for you. This will return to the task. 7. Click on Refresh 8. Change status to completed 9. Save and Return

25 Medication Adjustment First a manual erx check will have to be run for each patient where a prescribing action takes place. See Manual erx Eligibility Check. This can be done from the Face Sheet or from a Progress Note. From the Face Sheet : Click on the wheel beside medication list then to adjust a Medication click the +/- box.

26 Make the changes and click OK then SAVE

27 Notice under the Medication List or Plan the drug name that was adjusted is now in green and the +/1 box is darker. From the Progress Note Click Plan Insert Active Meds Click +/- box (same steps as from the facesheet SAVE (Hold/Charges) See Screen Shot next page

28