health informatics week 3

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CHAPTER

6 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

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

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

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

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

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)

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.

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.

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.

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.

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.

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.

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

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.