How we prepare patients at Skyline Family Practice with Patient Records

 

1) Day before (and also for Same Day Adds) - Staff print 3 items.

    a) Encounter form (printed)

    b) Chart Summary of that patient (printed)

    c) Routing slip (this one is one the PMSI web site under the forms section) - (the keep photocopies of these)

2)Above three items (routing slip stapled to the chart summary) are put on a clipboard as patient arrives -- then patient is moved to the exam room (clipboard, etc is in box outside of room)

3)Doctor/nurse - makes any notes on the chart summary / routing slip (that is if the EMR note isn't finished in the room at the time of visit)

4)At the visit's end - if the note is not done, the doctor takes chart summary / routing slip, fills out the encounter form with charges and any tests (attaching a requisition form if needed) and sends the patient to check out with these on the clipboard.

5)Doctor uses the chart summary/routing slip as their reminder to finish the chart (not the encounter form -- which is processed as patient checks out)

   BTW, the chart summary/routing slip is a workable backup system for power failure/system down time since most of the useful information on that patient

   is right there.  (There is nothing worse than having the system down and having to ask the patient what their meds / allergies, etc are!)

6)Once note done, doc puts it a hopper for eventual shredding (they're held in an accordion file [each day of the month].  This way these items are help for 30 days until the shredding.