Southwest Cardiology Physician Preferences

Transcription

1 Southwest Cardiology Physician Preferences Dr. Reddivari a. Pull in last office visit note. b. Add wild cards under HPI, ROS, EXAM, Cardiac History and Recommendations. c. If no old note is available, type.arconsultnote for new patients. 2. Problem List a. Use old note to enter problem list from last impression. b. For a new patient, he will tell you the diagnoses for you to add to the problem list. 3. Update / Add labs and imaging (Chart Review) a. Use labs that are within the last six months or so. i. Get labs from the Results Review tab as well as b. Make sure to delete duplicate imaging in the note. 4. LOS and Follow Up / Orders if necessary a. For established patients, use E4 unless otherwise specified by the doctor. b. For new patients, use N4 unless otherwise specified by the doctor. c. Fill in follow up date d. Enter and pend orders as necessary e. Remind doctor to sign orders. f. Read over HPI and Recommendations and correct for dragonisms / completeness. g. Close the encounter and route to PCP.

2 Dr. Wenzke a. Pull in the last office visit note. b. If there is no old note, type.fwoffice for new patients. 2. Problem List a. Copy the problem list directly from the last office visit in the same order as they appear on the office note. b. For a new patient, he will tell you the diagnoses for you to add to the problem list. 3. Update / Add labs and imaging (Chart Review) a. Delete the old EKG reading and put in EKG with today s date at the top of the Imaging section and put a wild card under it. i. Make sure to add the EKG after doctor reads it (type.ekgo in place of the wild card). b. Use labs that are within the last six months or so. i. Get labs from the Results Review tab as well as c. Make sure to delete duplicate imaging in the note. 4. Before doctor goes in the room, give him the following information a. Date of last office visit. b. Date and type of any hospital encounters (ED visit, Surgery, Admission, Etc.) since last visit. c. Date and type of new imaging since last visit. d. Date of most recent labs if they were done since last visit. i. If no new labs were done, make sure to tell him this as well. 5. LOS and Follow Up / Orders if necessary a. Order an EKG for next visit for every patient unless told otherwise. b. For established patients, use E and the number the doctor gives you. c. For new patients, use N and the number the doctor gives you. d. Fill in follow up date e. Enter and Pend orders as necessary f. Remind doctor to sign orders g. Route note to PCP h. Print Note and Current Meds list and file in the patient s chart. i. Put finished charts on countertop in the file room.

3 Dr. Karabatak 1. Doctor will create note and dictate the HPI and Plan. 2. Problem list a. Doctor will tell you the diagnoses as well as mention them in his dictation. 3. Update / Add Imaging (Chart Review) after doctor dictates the note a. Get imaging from the Cardiac Procedures and Imaging tabs as well as Care Everywhere. 4. LOS and Follow Up / Orders if necessary a. For established patients, use E and the number the doctor gives you. b. For new patients, use N and the number the doctor gives you. c. Fill in follow up date d. Enter and Pend orders as necessary. e. Read over HPI and Plan and correct for dragonisms and completeness. f. Have nurse sign any pended orders g. Close the encounter and route note to PCP.

4 Dr. Busch a. Type.cboffice for established patients. b. Type.cbconsult for new patients. 2. Update / Add labs and imaging (Chart Review) a. Use labs that are within the last six months or so. i. Get labs from the Results Review tab as well as b. Make sure to delete duplicate imaging in the note. 3. Problem List a. Doctor will give you the problem list before you enter the room for new patients. b. For established patients, copy and paste the problem list from the previous note into the new note. i. Also enter them in the Problem List tab. 4. Note (HPI, Vitals, ROS, Physical Exam) is entered in the room. a. He may dictate the plan to you and make corrections to your HPI after the visit. 5. LOS and Follow Up / Orders if necessary a. For established patients, use E4 unless told otherwise. b. For new patients, use N4 unless told otherwise. c. Fill in the follow up date. d. Enter and Pend orders as necessary. e. Remind doctor to sign orders as necessary. f. Doctor will close note and route to PCP.

5 Dr. Schwartz 1. With Todd a. Todd will start the note. b. Input Visit Diagnoses c. LOS and Follow Up / Orders if necessary i. For established patients, use E4 unless told otherwise. ii. For new patients, use N4 unless told otherwise. ii. For one year follow ups, order CBC, Lipid and CMP. iii. Fill in follow up date iv. Enter and Pend orders as necessary. v. After doctor closes the note, route it to PCP. 2. Without Todd a. Create a note i. For established patients, type.bsoffice for a blank note. ii. For new patients, type.bsconsult for a blank note. b. Update / Add labs and imaging into the note. i. Use.get phrases for labs. ii. This is done while in the room. c. Problem List i. Enter from last office note. d. Note (HPI, Vitals, ROS, Physical Exam) will be entered in the room. e. LOS and Follow Up / Orders if necessary i. For established patients, use E4 unless told otherwise. ii. For new patients, use N4 unless told otherwise. vi. Enter and Pend orders as necessary. vii. Fill in follow up date. viii. For one year follow ups, order CBC, Lipid and CMP. g. After doctor closes the note, route it to PCP.

6 Dr. Kiefaber a. Use.rkofficenote for established patients. b. Use.rkconsult for new patients. 2. Update / Add labs and imaging into the note. a. Use labs that are within the last six months or so. i. Get labs from the Results Review tab as well as b. Make sure to delete duplicate imaging in the note. 3. Problem List will be entered by doctor. 4. Note (HPI, Vitals, ROS, Physical Exam) is entered in the room. 5. LOS and Follow Up / Orders if necessary a. For established patients, use E4 unless seen in the last month, then use E3. b. For new patients, use N4 unless told otherwise. c. Fill in follow up date. d. Enter and Pend orders as necessary. e. Make sure you are finished with the note when you leave the exam room as doctor will immediately get into note and dictate. f. Doctor will close the encounter and route the note to PCP.

7 Dr. Jafri a. For established patients, pull in the last office visit note. i. Under HPI, type Since last office visit, and put a wild card before and after the paragraph. This is where you will start typing when in the room. ii. Do not delete the old HPI. Just add the above phrase at the bottom of the old HPI and sandwich between wild cards. b. For new patients, type.clinichp to get a blank note. i. Type HPI as you would for other doctors in a paragraph format. ii. Doctor will fill in wild cards in the HPI section from what you type. 2. Update / Add labs and imaging into the note. a. Use labs that are within the last six months or so. i. Always replace the labs that are highlighted green ii. Get labs from the Results Review tab as well as b. Do NOT delete duplicate imaging;; simply put the new imaging after the old imaging. c. Doctor has specific cardiac testing sections. If no tests are found in a section, type No records found in Epic 3. Problem list will be entered by the doctor 4. Note (HPI) is entered in the room. 5. LOS and Follow Up / Orders if necessary a. Doctor will choose LOS. b. Fill in follow up date. c. Enter and Pend orders as necessary. d. Doctor will close the encounter. i. If new patient, route note to PCP and Referring Physician. ii. If established patient, route note to Referring Physician.

8 Dr. Ahmad 1. Medical Assistant / Nurse will enter the appropriate note when rooming the patient. 2. Put in labs and imaging. a. Use the.get phrases to pull the labs into the chart. b. Enter only the imaging that he discusses with the patient during the visit as well as the last pacemaker or ICD check. 3. Problem List is entered by the Medical Assistant / Nurse when rooming the patient. 4. LOS and Follow Up / Orders if necessary a. For established patients, use E4 unless told otherwise. i. Use E5 if he discusses the details of a procedure during the visit. b. For new patients, use N4 unless told otherwise. i. Use N5 if he discusses the details of a procedure during the visit. c. Fill in the follow up date. d. Enter and Pend orders as necessary. e. Doctor will dictate his part of the note as well as close and route the note to the PCP.