Adult Patient Visit Workflow

Transcription

1 Adult Patient Visit Wrkflw 1. Check and recrd vital signs (see appendix A) This includes temperature, pulse, respiratin, and weight n all visits. Verbally ntify nurse r prvider fr critical actin abnrmals as indicated in the table belw: CRITICAL ACTION ABNORMAL VITAL SIGNS AND SYMPTOMS: MAs MUST VERBALLY NOTIFY NURSE OR PROVIDER FOR: VITAL SIGNS Bld Pressure Systlic > 180 Systlic < 90 Diastlic > 110 Pulse Pulse > 110 Pulse < 50 Irregular Pulse Respiratins Respiratins > 20 Wheezing Difficult r unusual breathing Temperature > 101 F < 96 F RAPID TESTS Fingerstick Glucse > 400, r HI < 60 Pulse Ox < 90% OTHER Cardi-Respiratry Chest pain Shrt f breath Appearance If yu think the patient lks ill; has signs f abuse; r have ther cncerns Prductive Cugh Give the patient a mask 2. Perfrm tests and services as indicate based n the fllwing guidelines: (Depressin Screen) PHQ-9: Any depressed patient cming in fr fllw-up shuld cmplete this while waiting fr the prvider. EKG: Patients ver 50 with chest pain; (ntify prvider befre EKG) Glucse Fingerstick: ALL patients with diabetes. Unless patient had fingerstick within previus 2 hurs. Staff shuld recrd the time that the patient last ate. Hemglbin A1c: Diabetic patients every 3 mnths if last A1c was > 7.0; nce every six mnths if last A1c <7.0 Pulse Ox: Patients with rapid respiratins, wheezing r cmplaints f shrtnessf-breath Peak Flw: ALL patients with asthma r COPD. Rapid Strep: Patients cmplaining f sre thrat 1

2 Rapid Flu A+B: Patients with flu expsure; headache, fever, myalgia during flu seasn Spirmetry: Annually fr ALL patients with asthma r COPD. (DO NOT DO THIS IF PATIENT IS HAVING TROUBLE BREATHING) Urine Pregnancy Test: Female patients with GYN cmplaints (unless the patient is past menpause r has a histry f hysterectmy); r if LMP > 6 weeks; r fr thse wh might require an xray; at request f patient; r fr Dep-prvera. Urine Dipstick: First save clean catch fr pssible culture. T be dne prir t clinician visits fr urinary symptms such as dysuria, frequency, urgency, plyuria, flank/abd pain, etc. Dcument if patient is currently menstruating. EXCEPTION: Males 11 and lder shuld cllect a first vid urine (first ml s f vided urine). Als dne fr Test f Cure visit ntify prvider if leukcytes r nitrates are psitive and send fr culture. Visin and Hearing screening fr patients cmplaining f visin r hearing prblems Vaccines: Flu, pneumnia, HPV, hepatitis B after screening 3. Verbally ntify prvider fr psitive HCG; any abnrmal UA (incl. heme r prtein); any psitive strep, flu, r RSV. 4. Update preventive care screen in the EMR. See Appendix A, #5. 5. Update the disease management tl in the EMR. See Appendix A, #6. 6. Update the past medical, surgical, family, and scial histry in the EMR based n the Adult Health Questinnaire. See Appendix A, # 7, 8 7. Review the medicatin list with the patient and ntify the prvider f discrepancies. 8. Ask the patient if they have any allergies.. Update allergy screen in EMR. See Appendix A, # Ask the patient if they have had any visits t a specialist, urgent care center, ER, r hspitalizatin since their last visit. If hspitalized utside f netwrk facilities, fill ut a medical release frm, have patient sign, and request recrds. Dcument that recrds were requested. 10. Gwn patient apprpriately: a. Female patients shuld be undressed & gwned frm waist dwn fr: Pelvic exams C/O vaginal discharge C/O pelvic r lw abdminal pain Other GYN cmplaints b. Patients shuld be undressed & gwned frm waist up fr: Breast prblem Axillary prblems Shulder injuries r pain Respiratry cmplaints Chest pain c. Patients shuld be gwned r dressed t expse the affected bdy part fr: 2

3 Rash Lcal abscess r injury Pain in ft, ankle, hip, knees, etc. Diabetic patients shuld have feet uncvered at all exams 11. Ntify the prvider that patient is ready t be seen. Check EMR desktp frequently fr rders, referrals, etc s that all preparatin fr checkut is cmpleted and all required dcuments are printed ut when patient arrives t check ut. 12. Discharge patient- See Appendix B a. Verify that an rder has been written fr all tests, supplies, treatments and medicatins and mark each as cmpleted. b. Print ut referrals, prescriptins, lab requisitins, patient educatin materials, and the chart summary- review each with patient. c. Reinfrce fllw-up dates r labratry/radilgy visit and verify telephne numbers. d. Offer specimen cllectin ptin at the practice, as applicable. 13. Disinfect table, change paper, tidy rm, wash hands and prepare fr the next patient. APPENDIX A BEGINNING THE PATIENT VISIT- use the belw as a wrkflw guide fr using the EMR 1. Lg int the EMR and bring up the patient 2. Review the Summary page a. Lk at the Prblem list and see if the patient has diabetes, COPD, asthma, r depressin b. Review the Care Alerts t see if there are specific patient needs 3

4 3. Click the Update buttn, and pen the Adult Preventive Care and Adult-Prblem Fcused/Fllw up r Pre-p template. Change the Prvider name t the respnsible prvider fr the visit Add in the reasn fr visit in the Summary line Click OK 4

5 4. The Vital Signs Template will autmatically pen a b c d e f g h a. Weigh the patient and enter in the weight fr tday. b. Review the patient height with them and check Ht- Reviewed unchanged r enter in the new height Nte- this is imprtant t calculate the patient s BMI c. Take the patient s pulse rate, temperature, and respiratins d. Take the patient s O2 Sat (pulse x) as indicated and recrd e. Recrd the LMP (last menstrual perid) fr female. Take nte if greater than 6 weeks. f. Dcument Vital signs measure by me. g. Take the patient s bld pressure and recrd. Dcument taken by me. h. Dcument the chief cmplaint (reasn fr visit). i. Click Next Frm. 5

6 5. Review the Preventive Care Tl a. Review each vaccine & test t see if there is a last result, declined, r exclusin (N/A) b. If blank, ask the patient if they have had the test r vaccine i. Any items that are prvided by the patient, need t be validated with results frm the rendering prvider. c. If patient declined the vaccine r test in the past r if it is indicated as due fr tday, ask if they wuld like it tday. d. Order any services the patient will be getting tday per standing rder prtcl that yur practice has adpted i. Flu annually ii. Pneumvax given nce age 65 and lder iii. HPV #2 and #3 refer t standing rder plicy iv. Mammgram refer t standing rder plicy e. Dcument declined as y if the patient declines tday. f. Review the BMI and assure it is ppulated fr tday. If nt, g back t the vitals screen and update accrdingly. g. Review Smking status- determine if dcumented in the past year i. If nt, g t the OV Risk frm and dcument current smking status as current, previus, r never *Als dcument alchl use n the next tab 6. Review the Disease Management Frm 6

7 If patient is diabetic Order a HgBA1C POC Test if dne mre than 3 mnths ag if >7. If less than 7, rder if date f test is greater than 6 mnths ag. Ask patient if they have been t the eye dctr r pdiatrist in the past year if last result greater than 1 year ld If yes, attempt t btain results If patient has CAD (crnary artery disease) Ensure Bld Pressure taken tday is ppulated If patient is Asthmatic Review the severity level If greater than a year ag, g t the Asthma/Reactive Airway Disease template Cmplete all 11 questins n the Asthma Severity ACCI G back t the disease management tl and assure severity level is there fr tday rder Spirmetry if last dne ver a year ag If patient has COPD Order Spirmetry if last dne ver a year ag If patient has depressin G t the PHQ9 and cmplete all 9 questins All patients Review when the PHQ9 was dne last If greater than a year, g t the PHQ-9 and cmplete questins 1 & 2 7

8 7. Use the Adult Health Questinnaire r interview the patient t update the Past Medical and Surgical Histry 8. Use the Adult Health Questinnaire r interview the patient t update the Family and Scial Histry 9. Enter in remaining rders per prtcl and the standing rder plicy yur practice has adpted 8

9 10. After cmpleting the apprpriate POC tests, dcument n the POC Tests Template 11. Immunizatins a. Cmplete the apprpriate vaccine screening 9

10 b. Dcument Immunizatins given tday using the Adult Immunizatins-CCC template 12. Review the Medicatin List with the Patient. Ntify discrepancies t the prvider. 13. Review/Cmplete the ALLERGY SECTION as fllws: Click n update Allergies buttn 10

11 If this sectin has nt been cmpleted, ask the patient if they have any Allergies, and enter these. If there are NO KNOWN ALLERGIES, click the this patient has n knwn allergies r adverse reactins check bx. If the sectin is cmplete, check the Allergy and adverse reactin list reviewed during this update. Click the OK buttn t clse the ALLERGIES screen. 14. End and hld the update fr the prvider APPENDIX B 11