Patient Intake to Patient Follow-Up Workflow worksheet

Resource: Patient Intake and Follow-Up Workflow Template

Reference Figure 7-16 in Ch. 7 (p. 176) of the textbook Health Information Technology and Management.

Complete the Workflow Template showing the process you will need to follow when assisting Dorothy from patient intake to patient follow-up.

Flow of an Office Fully Using EHRs

Earlier in this chapter Dr. Wenner and Dr. Bachman stated that an EHR changes the workflow of a medical office. Figure 7-16 illustrates the workflow of a visit to an office that fully uses the electronic capabilities that are available in EHR systems today, including patient participation in the process and the capabilities of the Internet. Follow the arrows in the figure as you read the descriptions of the steps listed here:

1. An established patient phones the doctor’s office and schedules an appointment.Internet alternative: Patients are increasingly able to request an appointment and receive a confirmation via the Internet.

• 2. The night before the appointment, the medical office computer electronically verifies insurance eligibility for patients scheduled the next day.
• 3. On the day of the appointment, the patient arrives at the office and is asked to confirm that the demographic information on file is still correct.
  

  

• 4. A receptionist, nurse, or medical assistant asks the patient to complete a medical history and reason for today’s visit using a computer in a private area of the waiting room. The patient completes a computer-guided questionnaire concerning his symptoms and medical history.Internet alternative: Some medical practices allow patients to use the Internet to complete the history and symptom questionnaire before coming to the office.
• 5. When the patient has completed the questionnaire, the system alerts the nurse that the patient is ready to move to an exam room.The nurse measures the patient’s height and weight and records it in the EHR. Using a modern device, vital signs for blood pressure, temperature, and pulse are recorded and wirelessly transferred into the EHR.
• 6. Subjective: The nurse and patient review the patient-entered symptoms and history. Where necessary the nurse edits the record to add clarification or refinement.The physician enters the exam room and discusses the reason for the visit and reviews with the patient the information already in the chart.
• 7. Objective: The physician performs the physical exam. The clinician typically makes a mental provisional diagnosis. This is used to select a list or template of findings to quickly record the physical exam in the EHR.The EHR presents a list of problems the patient reported in past visits that have not been resolved. The physician reviews each, examining additional body systems as necessary, and marks the improvement, worsening, or resolution of each problem.Assessment: Applying his or her training to the subjective and objective findings, the clinician arrives at a decision of one or more diagnoses, and decides if further tests might be warranted.
• 8. Plan of treatment: The clinician prescribes a treatment, medication, and/or orders further tests using the EHR.If medication is to be ordered, the physician writes the prescription electronically. The prescription is compared to the patient’s allergy records and current drugs. The physician is advised if there are any contraindications or potential problems. The prescription is compared to the formulary of drugs covered by the patient’s insurance plan and the physician is advised if an alternate drug is recommended (thereby avoiding a subsequent phone call from the pharmacist to revise the prescription). The prescription is then transmitted directly to the patient’s pharmacy.A built-in function of the EHR accurately calculates the correct evaluation and management code used for billing. The billing code is confirmed by the physician and automatically transferred to the billing system.When the visit is complete, so is the exam note. The physician signs the note electronically at the conclusion of the visit.
• 9. If lab work has been ordered, a medical assistant will obtain the necessary specimen and the order is sent electronically to the lab.
• 10. Patient education: Because of the efficiency of the EHR system, the physician has more personal time with the patient for counseling or patient education. In many systems the provider can display and annotate pictures of body areas for patient education, and print them so that the patient can take them home.When the patient is dressed, he or she is given patient education material, medication instructions, and a copy of the exam notes from the current visit. Allowing the patient to take away a written record of the visit enables better compliance with the doctor’s plan of care and recommended treatments.
• 11. The patient is escorted to the checkout area.If x-rays or other diagnostic tests have been ordered at another facility, the office staff may call on behalf of the patient and schedule the tests.If a follow-up visit has been indicated, the patient will be scheduled for the next appointment.
• 12. If lab tests were ordered, the results are sent to the doctor electronically, are reviewed on screen, and automatically merged into the EHR.If radiology or other diagnostic reports are sent to the practice electronically as text reports, they are imported into the EHR and can be reviewed by the physician.

 

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