ANECDOTALS
THIS IS HOW TO DOCUMENT ALLERGIES ON AN ANECDOTAL
WHAT IS WRITE IN RED INK AND HIGHLIGH IN YELLOW
THIS IS WHERE I SHOULD KEEP THE ANECDOTAL OVERNIGHT IF I DON'T HAVE TIME TO COMPLETE IT
IN THE ANECDOTAL BOOK
AFTER THE APPOINTMENT IF I DON'T HAVE TIME TO COMPLETE THE ANECDOTAL, THIS IS WHERE IT SHOULD BE KEPT
WHAT IS THE ANECDOTAL BOOK
THIS IS THE BEST TIME TO GET THE EXAM NOTES
ON THE APPOINTMENT
THIS IS THE BEST VIEW IN DA TO SCHEDULE AN APPOINTMENT FOR SOMEONE.
WHAT IS THE ENCOUNTER CALENDAR VIEW
THIS IS HOW TO DOCUMENT ALLERGIES ON AN ANECDOTAL
WHAT IS WRITE IN RED INK AND HIGHLIGH IN YELLOW
THIS IS MY PRIMARY ROLE FOR THE SHIFT MEETING
WHAT IS MAKE SURE THAT IT HAPPENS
THE DOCTOR'S OFFICE CALLS AND SAYS A TEST CAME BACK POSITIVE, AND HE MAKES A REFERRAL, THIS IS WHERE I WILL DOCUMENT THE INFORMATION FROM THE CALL
WHAT IS DOCUMENT ON A MEDICAL CONVERSATION SHEET
JANE'S RISPERDAL WAS INCREASED TODAY. THIS IS WHAT I WILL DO ONCE I RETURN TO THE RESIDENCE.
WHAT IS CALL THE BIS AND CALL THE RN. COMPLETE A HEALTH COMMUNICATION NOTE.
THESE TWO THINGS HAPPEN WHEN I SELECT FOLLOW UP ACROSS THE TOP OF THE ENCOUNTER AFTER SAVING IT.
WHAT IS A FOLLOW UP ENCOUNTER IS GENERATED AND THE FOLLOW UP APPOINTMENT IS ADDED TO THE E-CALENDAR
I CAN FIND WHAT THE DOCTOR NEEDS FOR THE NEXT/FOLLOW UP APPOINTMENT HERE
WHAT IS THE PLAN
IF NOBODY ELSE IS AVAILABLE TO DO THE SHIFT MEETING WITH ME, THIS IS WHAT I WILL DO
WHAT IS COMPLETE THE SHIFT MEETING FORMS AS USUAL
THIS IS HOW I ACCESS MEDICAL FORMS FROM THE INTRANET
WHAT IS OPEN TO THE HOME SCREEN, CLICK ON PROGRAM OPS AT THE TOP (UNDER THE BLUE STRIPE), CLICK ON MEDICAL FORMS IN LEFT COLUMN OR TYPE IN MEDICAL FORMS, THEN TYPE YOUR DOCUMENT IN THE SEARCH BAR
SALLY'S BS HAS BEEN CONCERNING HIGH FOR SEVERAL DAYS. YOU MAKE HER AN ENDOCRINOLOGY APPT TO HAVE HER EVALUATED. DR SAYS THAT RECENT USE OF STEROID D/C MED
CHIEF COMPLAINT
DESCRIPTION
DA CHIEF COMPLAINT: HIGH BLOOD SUGAR
DESCRIPTION: EVALUATE TO STABLIZE BS. RECENT USE OF STEROID CAUSING INCREASE. D/C PREDNISONE.
NEED TO DOCUMENT D/C PREDNISONE IN THE MEDS SECTION.
This is how you get to encounters in DA for an individual
What is:
apps, individual, My Health, Medical Encounters
THIS IS HOW I WILL PREPARE FOR AN UPCOMING APPOINTMENT
WHAT IS LOOK AT THE PREVIOUS ANECDOTAL AND BE SURE EVERYTHING ORDERED HAS BEEN DONE
TO RUN THE AM SHIFT MEETING, I WILL NEED THE FOLLOWING:
WHAT IS THE SHIFT MEETING FORM, THE PREVIOUS WEEKS APPOINTMENTS, THE CALENDAR FOR THE FOLLOWING WEEK AND THE LEVELS OF SUPERVISION NEEDED
THIS IS WHAT I AM GOING TO DO BEFORE I CALL THE NURSE.
WHAT IS TAKE VITAL SIGNS, CHECK PRN SHEET (TO SEE IF/WHEN THAT MED WAS GIVEN TO THAT INDIVIDUAL FOR THAT AILMENT) CHECK THE TREATMENT SHEETS AND PROVIDE THOSE TREATMENTS BEFORE CALLING THE NURSE.
THE DOCTOR ORDERS AN MRI WITH ORAL SEDATION, THESE ARE THE STEPS I WILL FOLLOW
WHAT IS NOTIFY BIS AND RN, CONTACT PSYCH/PCP FOR SCRIPT, GET
CALL RADIOLOGY FOR MRI PAPERWORK IF YOU DON'T HAVE IT, COMPLETE
The definition of Chief Complaint and an example
The definition of Description and an example of a definition for the above Chief Complaint
Example:
Description: How the Chief Complaint occurred
Example:
THE DR. SAYS SHE IS CONCERNED ABOUT RECENT BP READINGS AND REFERS PATIENT TO CARDIO TO EVAL BP MED FOR INCREASE. SHE WANTS PATIENT TO RETURN IN 3 MONTHS TO FU AFTER CARDIO. SHE ALSO SAID TO HAVE LABS DONE 3 WEEKS PRIOR TO APPT. WHAT DO YOU WRITE ON THE ANECDOTAL FOR THE REASON AND THE FU
REASON: 6 MONTH APE F/U. DR. CONCERNED ABOUT RECENT BP READINGS AND WANTS PT TO SEE CARDIO TO EVAL MED FOR INCREASE.
FOLLOW UP: CARDIO APPT EVALUATE BP MED, RETURN IN 3 MONTHS AFTER CARDIO, LABS 3 WEEKS PRIOR TO F/U WITH PCP BRING BP CHART
THIS IS WHERE I WILL LOOK TO SEE IF EVERYTHING HAS BEEN COMPLETED FOR THE PREVIOUS WEEK'S APPOINTMENTS PRIOR TO THE AM SHIFT MEETING
WHAT IS REVIEW STATUS OF APPOINTMENT IN ENCOUNTERS, VIEW MODE
THESE ARE THE STEPS TO SEND A HIPPA COMPLIANT EMAIL.
GO TO MY EMAIL AND OPEN IT, CLICK ON MY NAME (TOP RIGHT), SELECT OPEN ANOTHER EMAIL, TYPE IN RESIDENCEEFAX AND CLICK OPEN.
SELECT NEW AND IN THE TO BOX WRITE FAX NUMBER @SRFAX.COM
JOHN'S LIPITOR INCREASED TODAY, THIS IS WHAT I NEED TO DO WHEN I GET BACK TO THE RESIDENCE.
WHAT IS CALL RN, D/C PREVIOUS DOSE ON MED VERIFICATION & HX AND INPUT NEW DOSE ON NEW LINE, UPDATE FORMULARY, DO MED ALERT MAKE 9 COPIES, HEALTH COMMUNICATION NOTE 9 COPIES
FILL OUT TRACKING, ANECDOTAL, UPDATE MEDICATION IN DA
These are 4 of the 5 categories under My Health in Medical DA.
Health information, Healthcare Providers, Medical Encounters, Medications, Mental Health, Immunizations