Patient Walk-Through
One of the best ways to visualize how PracticeStudio® can help manage your office is to show a typical patient walk-through. This explanation will follow the patient from the initial enrollment of the patient, through medical record entry of the encounter, and finally to the check out procedures.
Front Desk Operations: As the patient enters the clinic, the first and obvious interaction is with the front desk personnel. As the patient signs in, several different options are available to the front desk person.
(a) If this is the first visit for the patient, the front desk person can perform a simplified patient enrollment. Typically this is limited to name, address, and gender. If more detailed information (i.e. insurance info) is known, then that data may be entered as well. Remember, multiple users can have simultaneous access to the patient’s account!
(b) Secondly, the patient will be "signed in" on the front desk computer. This function serves several requirements. First, existing appointments for the patient are "marked" so they will not be reflected on the "No Show" report / inquiry. Next, a "Routing Slip" may be printed for the patient. This acts as a disposable travel card that follows the patient through the clinic.
The Routing Slip is a soft template whose contents may be changed to match the requirements of the clinic. It typically includes balance information, diagnosis codes, and the most recent, pertinent chart information. A calendar may also be included showing all appointments scheduled for the patient.
(c) For new patients, the detailed insurance records may be entered at the front desk or be forwarded to the insurance staff.
Assistant Entry
Assistant Entry: Once the patient has been routed to an examination room, the CA will begin the initial entry for the patient’s encounter. The "History and Physical" button on the Homebase is typically selected first. This will guide the CA, screen by screen, in logical steps of entry.
Chief Complaint and HPI: The first entry screen presented is the Complete Chief Complaint and History of Present Illness form. This form includes all complaints for the Musculoskeletal and Neurological body systems.
All text is generated by touching the appropriate buttons, resulting in smooth flowing and discrete narrative data. There are over one hundred different complaints categorized in alphabetical order. These specific complaints were accumulated through years of experience with existing customer installations, providing depth and completeness in the data set.
The History of Present Illness entry is categorized into Location, Quality, Severity, Duration, Timing, Context, Modifying Factors, and Associated Symptoms. Again, these areas document all of the required E/M bullets.
Index of Forms: This screen permits the user to select the other narrative entry categories. Typically, the CA would enter the Past, Family, and Social History as well as a brief Review of Systems.
PFSH: Subsequent screens provide entry for all aspects of Past, Family, and Social History. A full complement of screens for recording all illnesses, surgeries, injuries, and prior treatment are included in this section.
One section of this entry includes a set of very detailed touch screens that permit exhaustive entry pertaining to automobile accidents.
ROS: Summary and individual body area Review Of Systems follow, allowing reporting or denial of symptoms in all pertinent body systems, particularly the Musculoskeletal and the Neurological systems. These forms include a "Denies All" button which quickly documents the E/M coding requirements, while allowing the CA to touch in pertinent positive symptoms.
Constitutional Exam: The next step for the CA is to enter the information pertaining to the Constitutional Exam. This form includes general information such as Height, Weight, Blood Pressure, Pulse, Respiration, and General Appearance. Again, the E/M coding bullet information is being calculated as the narrative text is generated.
Doctor Entry
Doctor Examination: After the assistant has completed the basic entry, the ChartView inquiry may be launched in preparation for the doctor’s entrance into the examination room. This form is a dashboard for all of the EMR entry for the patient. The doctor may review all of the information for this encounter, or for any encounter in the past.
The EMR data is grouped based on the discrete data types, including problems list, all past encounters, lab detail, and diagnosis codes. The patient’s photograph is available during this inquiry as it is during most posting forms.
Encounter Information: Each patient encounter is segregated by a date and time stamp. This allows review, printing, and maintenance on an encounter by encounter basis. Multiple encounters may be posted for the same date.
Examination and Review of Systems: The doctor may review and modify any of the information that has been previously posted by the CA. In addition, a complement of examination forms and review of systems forms are available for in-depth recording of the patient encounter. These include the forms for Constitutional, Neurological, Cardiovascular, Lymphatic, Musculoskeletal, and Integumentary body systems.
Wireless or Touch Screen: As mentioned previously, the ChiroX4 Data Set is designed to be used with touch screens or tablet PC’s. In some cases, a touch screen monitor and PC may be installed in each of the exam / treatment rooms. In other cases, wireless tablets may be used. Depending on the clinic layout and the desires of the physicians, one or a combination of both options may work best.
Previous Encounter Review: The doctor (or the CA prior to doctor access) may choose the Previous Encounter Review. This process will "roll forward" all of the pertinent history from the patient’s previous encounter. This is especially useful when seeing patients for a recurring problem. As the information is rolled forward, the doctor or CA will have the ability to review the data and change specific elements so that they match the current encounter findings.
Lab or Exam Results Review: For follow-up visits, the doctor may review all past lab or exam results. The ChronoGraph® features of ChartPower® will graph any numerical data. Selectable at run-time, the graphs may be formatted for a variety of line, bar, and pie charts. This is especially useful for graphing Range of Motion activity over the course of patient treatment.
Treatment
Treatment Options: As shown in the previous pages, examination and treatment, including adjustments and physical modalities, are handled on specialized forms.
Pain Disability Ratings: During the course of patient examination and treatment, it may be desired to measure the disability of the patient based on one of the accepted methodologies. This is accomplished via the Pain Disability button of the Homebase.
There are six disability rating methods contained on the rating form. These methods are: Oswestry, Vernon-Mior, Roland-Morris, General Pain, Modified Zung, and Modified Somatic.
After the questionnaires are answered by the doctor with input from the patient, the "Record Results" button may be selected to calculate the disability rating for the specified test for the patient’s encounter. This value can be reviewed and graphed via the ChronoGraph® functions as previously described.
Supplies Entry: Another function of the treatment phase may be to issue to the patient or instruct the patient on supplies that are provided at the clinic. These items may include vitamins, orthotics, pillows, etc.
Each of the supply items may be attached to corresponding CPT codes providing an automatic update to the billing portion of PracticeStudio®. Also, individual supply items may have specific instructions that are printed for the patient at check-out time.
Assessment & Check-Out
Assessment: Finalization of the patient encounter starts with the patient assessment by the doctor. The Assessment form displays the problem list for the patient. This problem list will show any chief complaint or diagnosis code that has been entered during the encounter. The doctor may elect to remove any item from or add any item to the problem list during encounter posting. Notations as to the patient’s prognosis and any follow-up visit information is entered at this time.
Excuses: One of the ChartPower® options includes the ability to record and print excuses for the patient. The data set includes Authorization for Absence, Return to Duties (with or without restrictions), and Care Certificates. Not only will the excuses be printed for the patient, they will be notated in the patient’s chart.
Lab Orders: As the doctor determines, Lab Orders are typically placed at this time.
X-ray Orders and Results: In addition to lab orders, the doctor may choose to order x-rays, MRI’s or other diagnostic tests during this phase. The data set also includes forms for creating narrative findings for the x-rays and MRI’s. In fact, individual x-ray reports may be produced if the doctor is consulting for other physicians.
Charge and Diagnosis Posting: Since PracticeStudio® is a comprehensive Electronic Health Record, CPT and Diagnosis notations made during chart entry may be automatically updated to the PracticeWizard® billing system. This feature eliminates posting steps as well as prevents errors due to mis-posting.
Patient Check-Out: Once the doctor has finalized the encounter, the patient typically navigates to the insurance / collection office or to the front desk. Any excuses and instructions that have been created for the patient will be waiting.
Since the charges have already been posted, the billing personnel can review the patient’s charges for the day, and collect the automatically calculated co-pay. The insurance plans, co-pay amount and type, and remaining deductible are all entered during patient enrollment.
This concludes a typical patient walk-through. The best part is, the EMR record is completed!
Overview |
Treatment Form |
Patient Walk-Through |
Narrative Reports |
EMR Add-Ons
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