Office Visit Basics. Office Visit Defaults

Transcription

1 Office Visit Defaults Important to Use Current for School Year, Date, Check In & Check Out time if your clinic uses Student Check-In Select any Visit Reason, Treatment, or Disposition Codes you would like prepopulated on all office visit entries (remember you can remove/change as needed on each student s office visit entry). Enter School and Examined By 1

2 Office Visit Entry Screen Verify correct student, school year, date, check in & out times; Profile/contact info enter Temperature, if taken Entity: campus Examined by: nurse or clinic assistant Notified: enter parent name, if called Note: details of assessment, interventions, treatments and disposition Visit Reasons: enter based on student complaint; student s enter with Student Check In kiosk nurse can edit reason; can enter multiple reasons Treatment: enter all applicable treatments/actions Dispositions: enter applicable disposition 2

3 Vital Signs tab: use to enter detailed vital signs with times Click Add to enter each set of VS by time Office Visit Basics Administer medications to students through Sch Medication or PRN Medication tabs click Administer and complete details Waiting List: Add student and put them in Queue (quick entry with Time In and OV Reason) Keep In Office: use to hold student in Queue to finish documenting record later or after the student is released/picked up Release Student: completes office visit entry & releases student from Queue (can view/edit from Student Profile/Office Visit tab) Add Diabetes: opens Diabetes Care Log tab from within open OV Add Injury: opens Injury Care screen from within open OV Add Physical: RISD does not use; Physical is used to document AN screening Back: go back out of entire OV without saving; don t use back button to toggle between OV tabs Warning: if you Add Diabetes, Add Injury or Add Physical and don t need the tab or document anything in it, a blank entry will be added in the associated Student Profile tab click the CANCEL button if you don t need it. 3

4 Add multiple, timed diabetes care events. Great for low BG visits! Links diabetes care with the office visit and adds the entries to both the Diabetes Care Log and Office Visit tabs in Student Profile Add Injury for urgent or emergent events (parent transport or EMS transport). Links injury entry to both the Office Visit and adds entry to both Injury and Office Visit tabs in Student Profile 4

5 Office Visit Entry multiple ways to enter OV! Check OV Entry by Date at the end of the day to make sure there are no students in Queue and to quickly review all OV entries (View Hist) Profile Access: look up parent phone# and other profile information by clicking on hyperlinked student name Thornton Billy Bob Refresh: refresh display if new students are checking in Add: add a new student office visit (if Student Check In kiosk not used) Edit: Edit an student in Entry by Date Queue that is Admit: Start entry on a student that has checked in using Student Check In kiosk and is Release Student: completes office visit entry & releases student from Queue (can view/edit from Student Profile/Office Visit tab) Void: void an erroneous entry Add Staff: enter an office visit on a staff member Defaults: set your Office Visit defaults (pre-populate fields for faster entries) Stu History: shows all office visits for a student in Queue (click on their Queue line to highlight, then click Stu History button) View Hist: shows all office visits for the day (can also toggle to previous days) 5

6 Profile Access: look up parent phone# and other profile information by clicking on hyperlinked student name Thornton Billy Bob Student Profile/Office Visit tab WS\OF\HR\TB\OV\OV or WS\ST\TB\HR\TB\OV\OV View office visit history; Add, Edit or Void an office visit. Add Notes to an existing visit (follow up documentation). Use to get parent contact information 6

7 Office Visit Quick Entry Waiting Queue displays students who have checked in (Student Check In kiosk OR Add by nurse/assistant); click Admit to document and add to Office Queue Office Queue displays students who have been admitted from Waiting Queue; to document highlight name to populate student in entry fields below Office Queue; click Edit Return: sends student back to Waiting Queue Refresh: updates screen with most current Queued students Not ideal area for RN documentationdoes not have meds, diabetes care, etc. Complete fields for office visit, including Visit Reasons, Treatments and Dispositions. Click on Notes to add narrative documentation; Save then in Office Queue Release student Use to get parent contact information 7

8 Student Check In Nurse/Staff can add from here to Queue students OR use Check In kiosk (laptop, computer, etc.) for student to check themselves in Student enters Other ID or Key, then Enter Selects Office Visit Reason(s) (set up to include/exclude Reasons in Codes table Click Done and they populate in to Waiting Queue NOTE: nurse/staff Office Visit Defaults must be set to Use Current Check In and Time Out so the student s check in time is correct in the Queue 8