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.

Nurse Entry

Once the patient has been routed to an examination room, the nurse will begin the initial entry for the patient’s encounter. The “Nurse Entry” button on the Homebase is typically selected first. This will guide the nurse, screen by screen, in logical steps of entry.

Constitutional Elements: The first entry screen presented is the Constitutional Exam. This form includes general information such as Height, Weight, Blood Pressure, Pulse, Respiration, and General Appearance. Of course, as the information is touched in, all E/M Coding bullets are being recorded.

The Dermatology data set also includes entry text for the Glogau Skin Types.

PFSH: Subsequent screens provide entry for all aspects of Past, Family, and Social History. An abbreviated list, including tobacco use and skin related history, is available to speed input. It is backed up by a full complement of screens for recording all illnesses, surgeries, injuries, and prior treatment.

ROS: Summary and individual body area Review Of Systems follows, allowing reporting or denial of symptoms in all pertinent systems. These forms include a “Denies All” button which quickly documents the E/M coding requirements, while allowing the nurse to touch in pertinent positive symptoms.

CC and HPI: The next step for the nurse is to enter the Chief Complaint and History of Present Illness. All text is generated by touching the appropriate buttons, resulting in smooth flowing and discrete narrative data. 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.

Current Medications: In a typical encounter, the nurse will then choose the RxWriter® option to enter all of the patient’s current medications and medication allergies. If this is an existing patient, the medication list from the previous encounter will be displayed for updating.

RxWriter® is a complete drug management portion of the Electronic Health Record software. The details of this feature will be explained later in the document; however, in summary, the drug database is replete with over 50,000 drug selections, with interaction and dosage checking being evident during prescribing operations. Detail drug image inquiries help the nurse choose the proper drug to record in the history.

Doctor Entry

After the nurse 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 medications, 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 nurse. 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, Eyes, ENMT, Neck, Lymphatic, Renal, Respiratory, Cardiovascular, Gastrointestinal, Neurological, Psychiatric, Musculoskeletal, and Integumentary body systems.

Wireless or Touch Screen: As mentioned previously, the Dermatology 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 physician preference, one or a combination of both options may work best.

Previous Encounter Review: The doctor (or the nurse 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 nurse will have the ability to review the data and change specific elements so that they match the current encounter findings.

Lab Results Review: For follow-up visits, the doctor may review all past lab 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.

Treatment

As shown in the previous pages, examination and treatment of lesions are handled on specialized forms.

Procedures: As the doctor determines, specific procedures may be performed using custom procedure work flows. The work flows currently included in the data set are: Accutane, Acne, General Injection, Chemical Peels, Consultation, Intense Pulsed Light, IPL Follow-up, Laser, Melanoma, Mohs’ Pre-op, Op-Notes, Post-Op Notes, Rosacea, Sclerotherapy, and Wart work flows.

RxWriter®: At any time, the doctor may branch to the prescription writer portion of the system. This drug database and management tool permits all required entry for creation and maintenance of the patient’s prescription. Over 50,000 drugs are available for selection.

Interactions: Of course, RxWriter® is replete in checking for drug interactions, dosage checks, and disease/drug checks. The doctor may browse all of the available drugs by generic or market description. A list of “favorites” is available to allow quick selection and fulfillment of the most commonly chosen drugs and dosage combinations.

Fax or Print: After prescription entry, the prescription may be faxed directly to the patient’s pharmacy of choice, or be printed at the clinic.

As always, the patient’s medical record is updated with all medication changes and additions.

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.

Patient Education and Excuses: One of the ChartPower® options includes a database of patient education articles. This incorporates over 3800 articles created by medical professionals and updated three times per year. Also, the doctor may elect to create permission slips 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. One add-on feature is the “Lab Exchange” portion of ChartPower®. Via industry standard HL7 techniques, Lab Orders may be automatically transmitted to different labs around the country. If the bi-directional interface is installed, the lab results will be automatically posted back to the PracticeStudio® system. These reports may then be reviewed by the doctor and marked appropriately when discussed with the patient.

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 prescriptions, education articles, or 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!