Documentation
Where do you document a same day cancelled appt?
In the visit reason of the appt, in a TE noting what the pt said & whether or not it was R/S. Also creating a billing alert after verifying any prior R/S that may have been mislabeled.
What is the first thing to do when pt arrives?
HELLO! Good morning we are so happy you are here!!!!!!!!!!!!!!!!!!!!!!!!!!
Front Desk check-in for EVERY PT
ROI, ID, INS, PMT due, ipad, verify pharmacy
How do I know if it was faxed?
What if a pt answers admits to the respiratory screen?
Ask the pt for further clarification, recent meds, illness, exposure, travel, COVID test, MASK or change to Telemed or ask someone for help
Where do you document presbyopia, myopia, dry eyes, missing eye ball, glass eyeball?
PMH, DO not add all this to PL
Schedule appt, give logs, give survey
How often do I need to document Flu vaccine?
Once if pt had it every season (AUG- MAY).
If pt refused- docuement once before Christmas & once between JAN- JUN
What do I do if the specialist is OON?
Redirect referral to in network provider & notify the pt with the new contact number.
Who's job is it to get the pt for checkout?
EVERYONES
Does Diverticulosis belong in the PL?
NO! PMH only
I roomed a pt, took vitals, administered a vaccine, now what?
DOCUMENT EVERYTHING YOU do in the chart, do not give it to someone else to document.
CC says F/U with visit notes, imaging etc. What do I need to do?
Check to see if we have the visit notes, imaging etc ASAP, preferably prior to the pt arriving.
What do I do if I receive a referral that states it is TO: Denise Bruckerhoff to Establish care, needs PCP or some other DX?
Schedule establish care visit.
Who's job is it to finish the pt when the doctor says pt need "XYZ"?
The person she is asking.
What is the VERY 1st step when updating PM on a chart on a TE in the Virtual Visit?
COPY FWD the last PM info to avoid losing it
Pt had labs, now what?
CODE THEM, but DO NOT CODE THEM WITH MAWV Z00.0
CC says with BS/ BP logs. What do I need to do?
Scan the logs! Don't just take them from the pt. If we are behind & they give it verbally- add it to HPI
90-120/ 80-90's, average 115/85
75-300, average 282
After I am done with a referral do I send it back to Dr. Bruckerhoff?
NO!
How do I get overtime approved?
Talk to Diana
Pt is unloading a bunch of info on me while I'm rooming pt. What do I do?
Remind pt of reason for appt, clarify pt priority.
Note refills/ details in HPI, so pt doesn't have to keep repeating themself if it is pertinent to the current visit, otherwise offer to schedule additional appt.
Pt came in for labs after their physical. They are coded from the previous visit, what do I need to do?
Change the preventative Z00.0 to read "Labs as part of a complete physical exam"
We are running really late, Dr. Bruckerhoff will not stop talking today. How can I help speed things up & go to lunch? I have already done the EKG, Spirometer & drawn blood?
Review PMH/ PSH/ Allergies/ SH & then tell the doctor you have already reviewed this with them in detail today. Check the PM for any missing docs to update, Review the vaccinations with the pt, update the COC.
When in doubt who to send it to?
Try to send to SWHR in network provider if local to us.
I am sick & can't come to work. What now?
Notify BOTH Dr AND Diana