Check-In and Newborn
What are 3 things that are documented in the reason for visit section during check-in?
chief complaint/concerns, preferred language, person(s) present at the visit with the patient.
Why is the PCP reviewed?
To verify the provider who primarily sees the patient OR did last WCC.
What medical records need to be obtained from other facilities for visit?
ED or hospital notes, newborn DC summary, consults, and labs
When is the vaccine information in CIIS reconciled?
Every visit
What is done if screening forms HAVE NOT been completed in YOSI?
Either print off for completion or have them complete electronically.
What VS are done at ALL VISITS?
Weight, height, HR, RR, Temperature
Why is the appointment type and length reviewed?
To ensure the correct appointment type is scheduled. 20 v 40 minute, Sick v WCC, 2fer appointments.
Why is YOSI checked?
To ensure all forms have been completed.
During sick season, what other vaccines should be offered?
Flu, COVID, Beyfortus (when would this be offered?)
What 3 screening questions are asked during check-in? And what is done with that information?
Current medications, drug allergies, preferred pharmacy. Notify provider for changes in the "reason for visit" notes.
What is included in the VS for WCC 3yrs+?
2 yrs and under?
3+ = BP and vision screening
2-= head circumference
Why is the printed schedule reviewed?
To verify WCC with asthma or other chronic conditions as well as joint scheduled appointments with other ECP care providers (Dental, BHP, CN, RD)
What if there are duplicate charts in Athena?
Let Andee, Rosa or your manager know so the charts can be merged.
Why are the VIS QR codes shown to the patient/parents during vaccine appointments?
It is a federal requirement.
When should the screening tools be scored and what is done with that information?
While the patient is still in clinic, verbally notify provider of any abnormal results.
When is the GHA created? What is added?
After the VS have been entered. Complete date, lead/hgb-15m-2yrs, and BP-3-4yrs+, and provider completed the rest.
Why are the appointment notes reviewed?
The chief complaint in the notes needs to be documented in the reason for visit since the schedule will not show the notes once the chart is prepped.
Why is the CIIS record printed for every visit?
To make sure there are no duplicate records and if there are, we are reporting them in CIIS.
Do orders (vaccines, meds, etc.) need to be signed by the provider before administering?
YES!
What is the process for patient handouts/care instructions?
Print out, add height, weight, and %. Give to provider with a ROR book. In Athena, check the box noting "discussed with patient" for care instructions.
What extra information is entered in Athena for newborn visits?
Add the social history, birth weight and birth history information (H&P, DC Summary, and Prenatal History)
What extra prep is done for a 2-month visit?
Obtain newborn screen results through the CDPHE Newborn Screen Portal.
What if there is no vaccine record in CIIS?
Start the process for obtaining the vaccine record from previous PCP, health department or school.
What extra items need to be done for asthma appointments?
ACT form completion, ask if they received/watched the asthma videos, print action plan if requested from provider.
What needs to be done at the end of the visit?
Print referrals and give to patient. (send to portal if encounter is closed). Schedule next appointment if able. Ask parent if any other paperwork (physical forms, school notes, etc.) is needed.