Office Visit

Below is important information for completing office visit. Please review periodically as things can change.

You can find your schedule using the calendar tab seen below. Please note that you may have patient’s added during the day if patient’s require “acute visits” for more urgent matters. Please check the schedule regularly.  

Pre-charting

We expect you to pre-chart on patients. It will help with agenda setting with the patient and ensuring that visits are focused on and efficient. This will also help you complete your documentation in a timely manner. 

You can pre-chart on any patient that is "Scheduled" by double-clicking on the chart. This will open the pre-charting space. As you can see below this space will allow you to review the chart, prepare a note, update the problem list, pend orders, etc. 

We recommend the following:

• Starting a note

• Reviewing any prior encounters under "Chart Review."  Please include in your note what happened at the last office visit with our office and any interval events since then. 

• Pending any due care gaps or labs with associated diagnoses that can reviewed with the patient during the encounter. You can always remove what you do not plan to use. 

In the Visit

In addition to the HPI and physical exam, please ensure the following is being completed in each office encounter:

Reconcile Medications

The MAs will go through and ask the patient about each of the medications on their medication list. They will document if the patient is taking the medication differently than prescribed or if they are not taking the medication.  They are not able to discontinue medications from the list.  This is your responsibility. So please review the medication list in the encounter with the patient and discontinue any medications that the patient is not taking.  The more information you give about why the patient discontinued the medication, the more helpful it is to the patient, your colleagues and specialists. 

Reconcile Problem List

With problem-oriented charting, it is important to review the problem list during every encounter and remove anything that has resolved. For example, if the patient had hyponatermia that resolved, you can remove it from the list by hovering over the "x" and choosing resolve. You can also use choose the merge feature to combine the same problem listed under several different names. 

Blood pressure

If >140/90, you need to recheck after 5 minutes AND document under vital signs under rooming tab. This is a Tower Health wide policy.

Placing orders

Please make sure that all orders are signed prior to the patient checking out. This will help ensure that the front desk staff can help the patient with scheduling imaging tests, printing lab slips if necessary and assisting with referrals. If you place an order AFTER the patient checks out, please notify your preceptor so that they can advise on whether the front desk staff or patient needs to be informed.

Additionally if a vaccine, ECG, urine, swab needs to be completed by an MA, please also notify them in addition to placing the order as they are busy and may not see the order was placed. 

Wrap up

Make sure written patient instructions are completed in the "Wrap-up" tab for every patient before the patient checks out. It should include imaging tests that need to be completed, when bloodwork should be completed and instructions for any new medications or medication changes. 

For more information regarding documentation, please check back for the Documentation and Billing page