1. Chapter 18

2. Select patient aftercare instructions Modify patient aftercare instructions Create patient aftercare instructions

3. Aftercare instructions Important points to remember What to be concerned about Medications Work status Work restrictions Follow-up Assessment and plan of care Summation Case closed Standard instructions Modifiable instructions Specific instructions

4. Once physician finishes placing orders, diagnosing, answering history, exam questions next step in workflow is aftercare instructions for patient to take home Problem-focused patient aftercare instructions automatically and electronically generate and indicate care suggestions in real time based on the patient’s problem list, which complies with Meaningful Use Core Objective 11

5. Aftercare instructions inform the patient as to what they can do, activities patient should limit, what do to for self care after patient leaves facility They also inform patient how to self treat, take prescribed medications and when to return to medical facility Workers’ compensation patients will specify whether patient can work without restrictions, with restrictions specified by physician, or incapable of working at this time MedTrak will send emails, faxes to employers with works status of employee’s condition. MedTrak also has a real time employer portal for employers to review their employee’s work related health care information over the internet

6. Important Points to Remember-instructions about what patient should/shouldn’t do to self treat injury/illness What to be Concerned About-instructions to inform patient about what to do if condition worsens Medications-instructions about whether or not patient should continue/stop medications that they were taking previously Work Status-physician’s recommendation about whether patient should/shouldn’t return to work or if there are work-related restrictions

7. Work Restrictions-instructions on what patient is encourage to do, should limit doing, not do while at work Assessment and Plan of Care-physician’s assessment of patient’s condition and detailed plan for treatment Summation-physician’s opinion of patient’s present condition Case Closed-physician uses this section to close workers’ compensation cases

8. Standard-wording for instruction is from MedTrak library of instructions Modifiable-a specific word/words in instruction, marked with brackets( ) on either side can be changed Specific-physician types in (or uses voice recognition) to create instructions that are specific to patient Place cursor in Instructions field on Visit Documentation screen (Figure 18-1) Click Instructions button to access first screen of patient instructions Do This! Pg. 224 & 225

9. On Instructions/Important Points to Remember screen, select the following MedTrak standard instructions by clicking the checkboxes: Reduce activity Left pain be the guide Rest and Limit Use ankle Click Submit Selections button again to advance to next screen of instructions. MedTrak moves to second screen since this section is comprised of several screens of instruction choices Do This! Pg. 226

10. On second Instructions/Important Points to Remember screen-select the following instructions by clicking on checkbox: Ice-Ankle Appliances-Left Ankle Appliance-Wear at all times Appliances-Left Ankle Appliance-Remove to bathe Click Submit Selections button to accept selections Screen refreshes with selected instructions in black (Figure 18-3) Click Submit Selections button again to advance to next screen of instructions MedTrak moves to third screen(Figure 18-4) You do not want to select instructions on this screen so click Submit Selections button again to advance to Instructions/Medications screen Do This! Pg. 228

11. If patient is not currently taking medications do not select any of the Medications Instructions…if they are look for their current medication and check this (Figure 18-5) If patient is already taking prescription or over-counter medications, instruct the patient as to whether the patient should continue or discontinue taking his/her current medications given the patient’s present condition. This is especially important when prescribing any additional medications for the patient Click Submit Selections button to advance to the Instructions/Work Status screen Do This! Pg. 229

12. On Instructions/Work Status screen select the following instruction by clicking on the checkbox: RETURN TO MODIFIED work duties Click Submit Selections button to accept the selection Work Status screen refreshes with selected instruction in black (Figure 18-6) Click Submit Selections button to advance to Instructions/Work Restrictions screen Do This! Pg. 230

13. On Instructions/Work Restrictions screen select the following by clicking on checkbox: (Figure 18-7) We Encourage the following- Click specific instruction button to right of instruction Next screen is Specific Instruction screen for Work/Restrictions/We Encourage the following instruction Figure 18-8 Type or use voice recognition software to enter the following instruction: “Limit walking and standing while at work. Try to do sit down work only” Click Submit Instruction button Instructions/Work Restrictions screen returns with specific instruction appearing under the instruction(Figure 18-9) Click Submit Selections button to advance to Instructions/Follow-Up screen Do This! Pg. 232

14. Instructions/Follow-Up screen select following instructions by clicking the checkbox: Return for next visit- Click specific instruction button to right of instruction Next screen is Specific Instruction screen for Return for next visit/Follow-Up (Figure 18-10) Type or use voice recognition software to enter “Call for another appointment after your orthopedic visit” Click Submit Instruction button-Instructions/Follow-Up screen returns with specific instruction now appearing under instruction(Figure 18- 11) Click Submit Selections button to advance to Instructions/Assessment and Plan of Care Screen Do This! 234

15. On Instructions/Assessment and Plan of Care screen select the following by clicking checkbox: Additional Comments for Plan-Discussion of treatment options/contingencies: Click Specific Instruction button to right of instruction Next screen is specific instruction screen for Assessment and Plan of Care (Figure 18-12) Type or use voice recognition software to enter “Discussed with Mr. Baker my initial findings of an unspecified internal derangement of left ankle, and the need for him to see an orthopedic surgeon as soon as possible.” Click Submit Instruction button-Instructions/Assessment and Plan of Care screen returns with specific instruction appearing under the instruction (Figure 18-13) Click Submit Selections button to advance to Instructions/Summation screen Do This! Pg. 235

16. Click checkbox for Condition on discharge: in Summation section type “fair” in modifiable instruction field to right of instruction-click Submit Selections button When there is modifiable instruction field to right of instruction brackets on either side of word/group of words designate modifiable part of instruction If more than 10 characters are needed for modification of instruction click specific instruction button to right of instruction Whatever is types in modifiable instruction field or on specific instruction screen replaces word(s) inside brackets Instructions/Summation screen refreshes with word fair under instruction(Figure 18-14) Do This! Pg. 238

17. After finishing selecting, modifying and creating specific patient aftercare instructions click Submit Selections button again to display Instructions/Overview screen (Figure 18-15) Instructions/Overview screens displayed selected information in black If you review and decide to modify instruction in a section click green cross to left of section name to access selection screen for that section of aftercare instructions Click Page Down button to scroll down to see next Instructions/Overview screen(Figure 18-16) Review Instructions/Overview screen click EXIT SCREEN button to return to Visit Documentation screen which displays a message that “Instructions have been marked.” (Figure 18-17) Do This! Pg. 238

18. You will need to print and turn in Mr. Baker’s aftercare instructions that you documented in the electronic health record Do This! Pg. 239