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CHAPTER

McGraw-Hill

Office Visit: Patient Intake

Learning Outcomes

When you finish this chapter, you will be able to:

6.1 Identify the four stages of patient flow.

6.2 Discuss the main sections of the patient chart.

6.3 Describe the procedures for recording a patient’s past medical, family, and social history.

6.4 Explain how allergies and intolerances are entered in the patient chart.

6.5 Describe the procedure used to enter patient medications.

6.6 Explain how the chief complaint is recorded in a progress note.

6-2

Learning Outcomes (Continued)

When you finish this chapter, you will be able to:

6.7 Explain how a patient’s vital signs are recorded in the patient chart.

6.8 Explain the uses of an intra-office messaging system in an EHR.

6.9 Describe how letters are created in an EHR.

6-3

Key Terms

family history (FH)
history of present illness (HPI)
past, family, and social history (PFSH)
past medical history (PMH)
patient flow
progress notes
review of systems (ROS)
social history (SH)

6-4

Teaching Notes: As you define each term (or have students attempt to define them), provide examples of each of them, either in scenario or documentation form, to help students connect the abstract terms to real life.

6.1 Patient Flow in the Physician Office

6-5

Patient flow—progression of patients from the time they enter the office for a visit until they exit the system by leaving the office after a visit
A typical patient flow consists of four stages:
Check-in
Patient intake
Examination
Checkout

Learning Outcome: 6.1 Identify the four stages of patient flow.

Teaching Notes: Expound on the patient flow stages:

Check-in: Patient signs in, receptionist asks questions about changes in insurance, etc. Payment might be collected.
Patient intake: Patient is escorted to exam room; initial interview is conducted and vital signs taken.
Examination: Physician conducts exam; may order lab tests or follow-up work; THIS MUST BE DOCUMENTED.
Checkout: Patient leaves exam room and heads to checkout desk. Any follow-up or subsequent appointments are scheduled; payment might also be collected at this time.

Direct students to Table 6.1 in the textbook to compare and contrast the patient flow in a paper-based office versus an EHR-enabled practice.

6.1 Patient Flow in the Physician Office (Continued)

6-6

Progress note—note documenting the care delivered to a patient, and the medical facts and clinical thinking relevant to diagnosis and treatment
Past, family, and social history (PFSH)—commonly used abbreviation for past medical, family, and social history
Past medical history (PMH)—patient’s history of medical problems, including chronic conditions, surgeries, and hospitalizations

Learning Outcome: 6.1 Identify the four stages of patient flow.

Teaching Notes: Put students into small groups, and assign each group one of the patient flow segments on slides 6-8 (PFSH, PMH, etc.) The group should come up with a list of potential questions a medical assistant might ask at that particular stage of the intake process to obtain the needed information. Follow up with a class discussion. List some of the questions on the board, and have students role play a few fictional patient intake sessions.

6.1 Patient Flow in the Physician Office (Continued)

6-7

Family history (FH)—detailed record of medical events among members of the patient’s family, including the ages, living status, and diseases of siblings, children, parents, and grandparents
Social history (SH)—information about the patient’s tobacco use, alcohol and drug use, sexual history, relationship status, and other significant social facts that may contribute to the care of the patient

Learning Outcome: 6.1 Identify the four stages of patient flow.

Teaching Notes: See notes on Slide 6.

6.1 Patient Flow in the Physician Office (Continued)

6-8

History of present illness (HPI)—description of the course of the present illness, including how and when the problem began, up to the present time
Review of systems (ROS)—inventory of body systems in which the patient reports signs or symptoms he or she is currently having or has had in the past

Learning Outcome: 6.1 Identify the four stages of patient flow.

Teaching Notes: See notes on Slide 6.

6.2 The Patient Chart in Medisoft Clinical
Patient Records

6-9

The main sections of the patient chart window in MCPR include:

Patient identifying information (at the top and the bottom of the window)
Chart folders (similar to paper folders)
Notes area (used to enter notes about the patient)

Learning Outcome: 6.2 Discuss the main sections of the patient chart.

Teaching Notes: Explain that the way to get to the patient chart is to perform a Patient Lookup , in which you can search by various fields, such as patient name or chart number.

Have students complete Exercise 6.1.

As you discuss the various sections of the patient chart window, direct students’ attention to Figure 6.3 in the textbook, which is a visual of the chart window. Note that the unlabeled folders can be customized for each individual practice.

6.3 Medical History

6-10

The medical history section of the patient chart includes three folders:
Past Medical History
Social History
Family History
Each history section of the chart consists of a single note.
To enter a patient’s history, open a patient’s chart, and click the appropriate history folder.
If none exists, it can be created by clicking Yes when a message appears.

Learning Outcome: 6.3 Describe the procedures for recording a patient’s past medical, family, and social history.

Teaching Notes: A history note always contains a heading with the date and time the note was entered. This is important for documentation and record keeping.

Ask students why they think each history section of a chart only contains one note.

6.3 Medical History (Continued)

6-11

To enter a patient’s history:
Open a patient’s chart, and click the appropriate history folder.
If no chart exists, it can be created by clicking Yes when a message appears asking about creating a new note.
Click in the body of the note and begin typing.
Click the OK button to save the note.

Learning Outcome: 6.3 Describe the procedures for recording a patient’s past medical, family, and social history.

Teaching Notes:

Have students complete Exercises 6.2, 6.3, and 6.4.

6.4 Allergies

6-12

To record and store patient allergies:

Click the Rx/Medications folder; the Rx/Medications dialog box is displayed.
To add a patient’s allergies and intolerances, click the Allergy button; the Allergy dialog box is displayed.
Complete the fields and click the OK button to save the allergy information.
The information will be added to the list at the top of the Rx/Medications dialog box.

Learning Outcome: 6.4 Explain how allergies and intolerances are entered in the patient chart.

Teaching Notes: Discuss the differences between an allergy and an intolerance (allergies are more severe); note that once an allergy or intolerance is entered into a patient’s chart, MCPR will automatically check for interactions with a new prescription.

Discuss the fact that allergies and intolerances should routinely be reviewed; ask students why this is so.

Have students complete Exercise 6.5.

6.5 Medications

6-13

There are three tabs in the Rx/Medications dialog box:
Current
Ineffective
Historical
To enter patient medications:
Use the Current tab of the Rx/Medications dialog box.
Click the New button to record current medications; the Prescription dialog box will appear.
Complete the fields in the Prescription dialog box.

Learning Outcome: 6.5 Describe the procedure used to enter patient medications.

Teaching Notes: Explain that current medications are those currently in use; ineffective medications have been discontinued because of ineffectiveness; historical medications have been discontinued BUT were effective.

Note some of the various fields students will need to complete in the Prescription dialog box: template code, date, frequency, duration, etc.

Have students complete Exercise 6.6.

6.6 The Chief Complaint

6-14

In most practices, the chief complaint is entered as the title of the progress note for the patient’s visit.
To create a progress note (chief complaint):
A patient chart must first be open.
Click the Note button on the toolbar, or, to open an existing note, click the Progress Notes folder.
Enter the title and date as needed, and click the OK button.
MCPR allows for the use of shared notes, which are signed by each contributor.

Learning Outcome: 6.6 Explain how the chief complaint is recorded in a progress note.

Teaching Notes: Ask students – if the chief complaint, or reason for a patient visit, is usually the title of a progress note, why might there be space for up to five titles within a note?

Discuss the use of PINs and multiple signatures within a shared note – why is the system organized this way? Benefits? Drawbacks?

Have students complete exercise 6.7.

6.7 Vital Signs

6-15

Patients’ vital sign measurements are entered in the Vital Signs folder in the patient chart.
To record a patient’s vital signs:
Click the New button; the Vital Signs dialog box is displayed.
Select the keypad feature via a drop-down list; then enter numeric entries by using this keypad or by typing directly in the field.
Click the OK button to save the entries.

Learning Outcome: 6.7 Explain how a patient’s vital signs are recorded in the patient chart.

Teaching Notes: Ask students to list common vital signs – height, weight, temperature, pulse, blood pressure; note that MCPR highlights abnormal readings in red, which is a nice feature for easy reference.

Have students brainstorm what steps might be taken if a patient has abnormal vital sign readings. Discuss the benefits provided by the software program’s automatically highlighting abnormal readings in red.

Direct students to Figure 6.14 in the textbook, which shows the Vital Signs dialog box.

Have students complete Exercise 6.8.

6.8 Messages

6-16

Staff members can send intra-office messages using MCPR.
Messages can be used to:
Communicate with staff members
Set up a reminder system or to-do list
Send attachments
Link the reader to the relevant portion of a patient’s chart
Send messages ranked by priority

Learning Outcome: 6.8 Explain the uses of an intra-office messaging system in an EHR.

Teaching Notes: Explain that this function works like inter-office email. Ask students to debate the necessity of this feature – if everyone is working together in one office, why do the employees need to send messages?

Ask students to complete a sample intra-office note that might be sent in a real practice.

Have students complete Exercises 6.9 and 6.10.

6.9 Letters

6-17

Letters are sent to patients, other providers, employers, insurance companies, and others.
To create a letter in MCPR:
Click the Letter button on the toolbar, or select Letters on the Task menu; the Insert Template dialog box will be displayed.
Select a template from the list of letter templates and click the Insert button; the template will be inserted into the body of the letter.
Write the letter and click OK to save when done, or use the Print button.

Learning Outcome: 6.9 Describe how letters are created in an EHR.

Teaching Notes: Note that in MCPR, letters are note-based like patient histories and progress notes; templates can be set up. Ask students to discuss the benefits and drawbacks of using templates. Ask students to brainstorm the types of letters a practice might need to create (payment reminders, appointment reminders, provider letters to referrals/specialists, etc.)

Have students complete Exercise 6.11.