1. Out the Door (Overview) Chapter 12

2. Objective  Understand the Visit Documentation screen

3. Key Concepts  Subjective  Objective  Assessment  Plan  SOAP notes  Right information to the right person at the right time  Targeted information  Blink speed  Visit documentation  Out the door  Evaluation and management(E/M)-also referred to as the level of service

4. Out The Door  Efficient medical workflow-minimizes time takes physician to document subjective/objective findings based on exam, assessment of condition and plan for treatment  These components=SOAP  Subjective  Objective  Assessment  Plan

5. Out The Door  Present the right information to the right person at the right time  MedTrak does this by presenting only information needed at the time to make decision when requested.  Reduces clutter on screen so clinicians can focus on targeted information  Reduces weight of each screen-amount of data downloaded which allows instantaneous screen changes

6. Streamlined  MedTrak streamlines order entry process by problem-focusing the order selection screens to present most likely orders that physician would need for presenting problem(s) with minimal clicks of mouse

7. Presenting Targeted Information  MedTrak developed processor for physicians to use visit documentation which includes these sections:  Additional orders needed for patient’s care  Referrals to specialists/specialized testing  Diagnosing  Documenting the history/exam findings(subjective/objective data)  Aftercare instructions for patient to take  Evaluation and management(E/M) level of service

8. Documentation Screen  Place cursor next to patient’s name click Out The Door button  Term originated when MedTrak was being developed to run the emergency department of a hospital. During visits to ER we would hear physicians telling ward clerk that they were done with patients and wanted them “out the door.”

9. Two-Minute Drill  Goal was to have physicians place additional orders, order a referral, enter patient’s diagnosis, prescribe for patient, provide patient with aftercare instructions and select patient’s level of service in 2 minutes are less  This was achieved without documenting the history and exam portions-which are the only 2 portions that do not have to be documented before the patient leaves the facility as no charges relate to these

10. Out The Door Review  Visit documentation screen enables physician to document patient’s visit by working down the section on screen  Screen refreshes as physician documents to show the work  Top of screen displays date of service for visit, clinical staff’s answer to medication allergies questions, patient’s name, reason for visit

11. Figure 12-1

12. Orders  Enables physician to:  Place additional orders using problem- focused order entry method  Place additional orders using order codes than can be entered directly on screen  Cancel an order  Access the open orders processor to document an order

13. Referral/Authorizations  Enables the physician to:  Place an order for patient to see specialist (orthopedic surgeon, dermatologist, etc.)  Place an order for physical therapy, occupational therapy, chiropractic care  Place an order for MRI, CT scan, EMG or other scheduled testing

14. Diagnosis  Enable physician to choose, maintain the diagnoses using:  Problem-focused diagnoses tree based on physician’s checklist  Find DX process that provides seven different ways to locate diagnosis  Top 60 DX process that displays most common diagnoses on one screen  Add DX process that starts at top of diagnosis tree  Delete DX process to remove a diagnosis

15. History And Exam  Enables physician to document history/exam findings:  History/Exam questions based on diagnosis  Physicians can use check box process with touch-screen tablet  Physicians can use voice recognition software  Physicians can dictate history/exam finding to transcriptionist  Physicians can type answers using keyboard and stored response processor

16. Medications  Enables physician to:  Order both dispensed/prescribed medications using problem-focused order entry process  Order both dispensed/prescribed medications using order codes process  Cancel a medication order

17. Instructions  Enables the physician to select patient’s problem-focused aftercare instructions based on diagnoses. Physician can:  Instruct patient as to what to do at home  Instruct patient as to what to do at work  Document patient’s plan of care  Schedule patient’s next appointment with minimal effort

18. Level Of Service  Enables physician to select level of service for visit:  Based on complexity of history, exam, decision-making for primary care  Based on type of visit for orthopedics  Provides first aid designation for worker’s compensation visits  Provides for consultation visits

19. Done Or Not Done  Enables physician to indicate whether the visit documentation is done or not  Sometimes physicians are interrupted with phone calls from patients, questions from clinical staff and cannot finish documenting the visit at that time  Physician can return to this screen when they have time-however, patient will not be discharged from Clinic Status until physician indicates that he/she is Done with patient and they are “out the door”