During check-in, the patient arrives at the office and proceeds to the front desk. The front desk staff member checks the patient in, recording the time he or she arrived. The staff member confers with the patient to determine whether any information, such as a change in insurance or employment, needs to be updated in the patient record. The patient may be asked for payment at the time of check-in. Once check-in is complete, the patient takes a seat in the waiting room.
The patient is escorted to the exam room, where the medical assistant interviews him or her to obtain detailed information. Generally, the purpose of the interview is to:
- Obtain past medical, family, and social history
- Review allergies and medications
- Determine the chief complaint
Once the interview is complete, the medical assistant measures the patient's vital signs and prepares the patient for the examination. After the medical assistant has completed these tasks, the provider is notified that the patient is ready to be seen.
The provider reviews the patient's previous records, and then enters the room and examines the patient. During the encounter, the provider may order lab work or diagnostic tests. Medications may be prescribed. The provider develops a treatment plan and completes the examination. The details of the encounter must be documented.
The patient leaves the exam room and proceeds to the checkout desk. During checkout, the office staff gives the patient any additional information required, such as patient education materials or lab work instructions. If necessary, a follow-up appointment is scheduled. Before the patient leaves, the staff member collects any payment that is due, if it was not collected during check-in.
Information Collected During Patient Flow
Vital signs, Chief complaint, Progress notes, Past, family, and social history (PFSH), Allergies, Medication list, History of present illness (HPI), Review of systems (ROS), Diagnosis and assessment, Plan and treatment
The Patient Lookup Dialog Box
There are three tabs in the Patient Lookup dialog box: General, Name, and ID.
The medical history section of the patient chart includes three folders:
1. Past Medical History: Chronic illnesses, hospitalizations, and other health information
2. Social History: Medically relevant information about the patient's life, such as marital status, tobacco and alcohol use, habits, and work
3. Family History: Medically relevant information about the patient's family, including major diseases and chronic conditions
When a new medication is prescribed for a patient, MCPR checks whether the patient has any allergies or intolerances. While an allergy is a relative rare condition in which the immune system responds to a medication and causes adverse effects, an intolerance is generally a milder reaction, and does not involve the immune system.
(Patient allergies are recorded and stored in the Rx/Medications folder of the patient chart.)
In many medical offices, a medical assistant is responsible for reviewing medication lists with patients when they come in for an office visit. The patient or a family member is asked to look at the list of current medications and indicate whether anything has changed. Medications that have been added, discontinued, or changed are noted in the patient chart.
There are three tabs in the Rx/Medications dialog box:
1. Current: Lists current medications
2. Ineffective: Lists discontinued medications that were ineffective
3. Historical: Lists discontinued medications that were effective
The Chief Complaint
In most practices, the chief complaint is entered as the title of the progress note for the patient's visit. Progress notes can be created only when a patient chart is open.
(To create a new note, click the Note button on the toolbar. To open an existing note, click the Progress Notes folder in the patient chart.)
Shared Progress Notes
A shared note is commonly needed when a medical assistant or nurse begins a note, and a physician completes the note. If a progress note has been started but is not complete, it can be saved as an incomplete note by clicking No when asked whether you are permanently finished with the note. A feature in Medisoft Clinical Patient Records allows a shared note to be signed by each person who contributes to the note. To sign an incomplete note, "Shared_Note_Signature" is entered into the progress note. The program then prompts the user for his or her signature PIN. Once the PIN is entered, the signature is added to the note.
Patients' vital sign measurements are entered in the Vital Signs folder in the patient chart. The dialog box displayed in lists a patient's vital signs, including height, weight, temperature, pulse, systolic blood pressure, and diastolic blood pressure, among others. Vital signs taken over a period of time can be viewed in a table or a graph. Abnormal values are highlighted in red (high) or blue (low) on the Vital Signs screen. Blood pressure readings can be entered manually or imported from a digital monitor.
(To enter a new set of vital signs, click the New button. The Vital Signs (New) dialog box is displayed.)
Using Medisoft Clinical Patient Records, staff members can send intra-office messages. The messaging feature works like an internal e-mail system. It is used to send messages to other staff members or providers, and it can also be used as a reminder system or to-do list. A message can contain attachments and can include a link to the relevant portion of a patient's chart.
(To access the messaging feature, select Messaging on the Task menu, or click the Msg button on the toolbar.)
Letters are sent to patients, other providers, employers, insurance companies, and others. Patients are informed of test results and reminded about annual exams. Other providers, such as specialists, are asked to provide care to patients. Letters are sent to employers to document patients' absence from work. Insurance companies receive letters that state the medical necessity of care or follow up on denied insurance claims.
Letters are created by clicking the Letter button on the toolbar, or by selecting Letters on the Task menu, which opens the Insert Template dialog box.