Download
1 / 61
650 likes | 806 Views
EMR Work Flow. KNIGHTS Clinic at Grace Medical Home. Logging in for the FIRST time. Username and password- Username is first initial and last name with first initial and first letter of last name capitalized (ex. John Smith – JSmith ) Password: Temporary password is “password”
E N D
EMR Work Flow KNIGHTS Clinic at Grace Medical Home
Logging in for the FIRST time • Username and password- • Username is first initial and last name with first initial and first letter of last name capitalized (ex. John Smith – JSmith) • Password: • Temporary password is “password” • ** you will be asked to change this eventually** • Open 3 tabs: • Click on Run in the upper left and open: • ChartView • Schedule • Tracker • You will not have to do this step again!
To review patient history • Go to schedule, find your patient, right click and select “Launch Chart” • From there, choose health summary (upper left side) and you can scroll through the categories
Once the patient has checked in by the front desk... Placing a patient in a room • When you are ready to bring the patient back - go to the tracker, and move patient to the correct room (remember, you need to select the physician you are working with in order for the patient to pop up on the left “in the waiting room”) • This is your first important time marker!!
Once patient is in the correct room, click on their name again on the tracking board and click “collect vitals” (this will open the patient’s chart) • ***this is your second important time marker!!***
“Reminders” • When first opening a patient chart click “Reminders” on the tool bar • Reminders will then appear on the side of the screen • If a reminder is addressed during the visit it needs to be removed manually by clicking the red “remove” sign • When first opening a patient chart at the bottom of the home screen will be a list of rules. Click “Run All” to refresh the list (NOT “Refresh”) • These rules are important items that need to be addressed with the pt during their visit • When the rules are addressed and properly documented they will automatically be removed from the list
Starting a New Doctor’s Note • To start your new Doctors Note- click on the piece of paper and select “Doctors Note” • Select your attending physician as “Health Care Professional” and yourself (student) as “Assistant”
Ok, I’ve seen the patient. Now what? • Take a few minutes to discuss, talk to Patient Education, then present to attending physician • ***if you feel comfortable, begin filling out electronic document while speaking with attending physician*** • The next step is to see the patient one last time with your attending
Seeing the patient with an attending • ***REMEMBER- go back to tracker, right click on patient name and select “With Physician” • ***this is your third important time marker!!*** • Confirm plan with the attending- including any labs, medication, or procedures that need to occur before the patient leaves • **DO NOT ENTER ANY LABS WITHOUT CONFIRMING WITH THE ATTENDING**
Filling out the Electronic Note • First, choose your CC (Chief Complaint) • Once you have a chief complaint, you can now skip down to the plan ** • Remember to ALWAYS CHOOSE “Grace General Medical Plan” • From there, you can specify what needs to be done with your patient. • Once you have entered all information, the lab/pharmacy etc can do their job so the patient can leave ASAP • ** don’t forget to enter patient education information—patient education should give you the handouts they gave the patient so you can select the correct information—this is under the “plan” section of the document
Filling out the Electronic Note • Now, go back and fill in the rest of your document Vitals, Physical Exam, ROS etc. • ** remember, if patient has been here before, all PMH/Meds/Allergies etc should be on the left hand side— • **verify this information with the patient, add or delete as necessary and make sure to click “Reviewed” for each box. • This information can now be transferred over to your document by using the small arrow tabs next to the abbreviated category names on the left hand side of your document- • Click on the arrow and on the drop down box click add! • *** if you change anything on the left after adding to your document, remember to just click “Refresh” and your document will be updated.
Adding Vitals and Items from the Health Summary to the Doctors note
