clinical standards for health care information MO 250 SEMINAR 3 clinical standards for health care information

Compare and contrast patient flow in a paper based office and in an office that has an electronic health record (EHR). Patient fl ow refers to the progression of patients from when they enter the practice’s system by scheduling an appointment until they exit the system by leaving the offi ce after a physician visit. Between entering and exiting, many clinical and administrative events take place.

Step 1. Pre-visit: Appointment scheduling and information collection- CAN schedule online Step 2. Patient check-in and payment collection Step 3. Rooming, measuring vital signs, and patient examination and documentation Step 4. Patient checkout Step 5. Post-visit: Coding and billing, and reviewing test results. SEE PAGE 72 IN BOOK

Electronic check-in offers several benefits, including: Shorter waiting times for patient check-in No need to file paper forms in a patient chart Fewer errors, since information is entered once by the patient, rather than by the patient plus by the person who inputs the information in the billing program. medical assistant, checks the patient’s vital signs. Some offices use digital devices that measure the vital signs and transmit them directly into the HER. SEE page 76

Vital signs: Measurements of a patient’s temperature, respiratory rate, pulse, and blood pressure. Chief complaint: A brief description of the patient’s current problem in his or her own words. Progress notes: Notes documenting the care delivered to a patient, and the medical facts and clinical thinking relevant to diagnosis and treatment. Past medical history (PMH): The patient’s history of medical problems, including chronic conditions, surgeries, and hospitalizations. This should include any illness (past or present) for which the patient has received treatment.

Family history (FH): The medical events among members of the patient’s family, including the ages, living status, and diseases of siblings, children, parents, and grandparents. This includes diseases related to the chief complaint as well as any hereditary diseases. Social history (SH): Information about the patient’s tobacco use, alcohol and drug use, sexual history, relationship status, and other significant social facts that may contribute to the care of the patient. Allergies: A list of the patient’s known allergies, including reactions to each one. Medication list: Includes all currently prescribed medications as well as over-the-counter and nontraditional therapies. Dosage and frequency should be noted.

HPI (history of present illness): A description of the course of the present illness, including how and when the problem began, up to the present time. It includes everything related to the illness or condition, including aggravating and alleviating factors, associated symptoms, previous treatment and diagnostic tests, related illnesses, and risk factors. ROS (review of systems): An inventory of body systems in which the patient reports signs or symptoms he or she is currently having or has had in the past. Diagnosis and assessment: The physician’s thinking about the cause of patient’s problem as well as any tests performed to come to this determination. Plan and treatment: The physician’s thinking about the intervention that will be necessary to cure or manage the patient’s condition, including medications, procedures, and lifestyle changes.

In an office with an EHR, all test orders, prescriptions, and educational materials are waiting for the patient at the checkout desk. The front desk staff member reviews the billing screen in the EHR to see if any additional payment is due and schedules any follow-up appointments before the patient leaves. BILLING- coding look up v in computer. Dr doesn’t deal with day sheets in EHR

EHR systems also flag clinical info for pt’s like age recommended labs/tests. RX- info right there with dosaging etc. RX info cannot be emailed to pt yet. EHR NOT for ordering supplies. Formulary=list of pharmaceutical products and dosages deemed by a healthcare organization to be the best, most economical treatments for a condition or disease. Remember these are for clinical issues not financial! SOAP stands for:Subjective, Objective, Assessment, Plan. Used by the provider to enter progress notes? Keyboard, Voice recognition, clinical templates. MID TERM UNIT 4

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