Ambulatory
UHMG Psych Goldenberg Workflow- Full Electronic Documentation
Prep Work:
All
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Review My Active Tasks for tasks that are assigned to you
Goldenberg
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Review Worklist tab for your incoming results and Rx refill requests. ‘Verify’ and/or ‘Authorize’ and task
to clinicians. PRN
Review Tasklist /Worklist tab for physicians that you are covering. Sort by abnormals by clicking on the
exclamation point (!) to review those results as needed. Create an addendum for results if you take
action, but do not verify them so they remain in the ordering providers’ queue for review upon their
return.
Ensure that all charges and notes have been completed for the prior days’ patients
Access Community Record – In the bottom right portion of this window, click the “Community” button
to access community record to review patient documentation as needed
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Patient Intake
Douglas
Moore
Resident
Neal
Goldenberg
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If a resident wants Neal Goldenberg to see a patient they will send him a consult letter
In the consult letter header indicate the reason for the referral
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Review progress notes generated by Douglas Moore residents to determine whether or not to
see certain patients
If you will see a certain patient, search for patient in aEMR and send “Referral Order Follow Up”
task to the appointment schedule team task list and indicate that you will see that patient
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Patient Visit:
NOTE: Bold items in teal items appear on Clinical Summary for patient and should be completed by you before the
patient leaves. The other items can be completed after the visit.
Douglas
 Arrive patient in Athena and complete all current tasks done in Athena
Moore
 Info – Access ( i ) information button
Front Desk
 Update FYI and Chart Alerts as needed (PRN)
 Enter patient preferred communication
 Set clinical summary to ‘print’
 Update/Verify retail and mail order pharmacy Information
 Update/Review Patient Care Team
 Save changes
Patient Location: Update patient indicator to “Waiting Room”, and status to “MA Ready”
MA
 Info – Access ( i ) information button
o Review/Add FYI and Chart Alerts as needed (PRN)
o Collect Advance Directives and scan into Ambulatory Scan (PRN)
 MU Transition of Care – Determine if patient qualifies for transition of care (TC)
 MU Vitals – Weigh and room patient, collect vital signs and enter in UHCare
Ambulatory, (MU vitals include height, weight, BMI, and BP > 3yrs)
 Chief Complaint – Enter appropriate CC. If chief complaint doesn’t appear in ACI, use “Visit for Other”
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Start Office Note
o Specialty: Psychiatry, Visit Type: Office Visits > Psychiatry Consultation Initial
Add / Complete OH Screening Form while in office note
Published date 6.3.2013
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Physician/
MDs only
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o Right Click Note Menu > Add Section > Select ‘Screening’
o Right Click ‘Screening’ > Add Form > Search for “Screening” and select option
Click on Save and Close to save changes to the note
Patient Location: Update patient indicator to “Room #”, and status to “Provider Ready”
Physician
Patient checks in at front desk on Walker Floor
 Front Desk will send email when patient is ready
Tasks – Review tasklist for the patient to ensure nothing is missed PRN
Info – Access ( i ) information button
 Update the ‘Patient Care Team’ with your info if desired.
Update FYI PRN
Open Note – Click on note icon generated by the MA from daily schedule
 Ensure attending provider name is selected in Note Owner Field
MU Chief Complaint – Must add Chief Complaint by ACI, if none applicable use “Visit for:
Other.”
 Continue to update in free text if needed.
MU Meds/Allergies – Reconcile the Current Meds and Allergies from the clinical desktop
MU Social Hx (enter in smoking status for the patient). Enter in ACI history builder section.
Choose from list of smoking favorites. (Only on patients older than 13 years of age)
Medical History Review
Active Problems - review and add if appropriate
Past Medical History - review and add if appropriate
Surgical History - review and add if appropriate
Family History - review and add if appropriate
HPI – Add additional narrative if necessary.
ROS – Verify RN entry and use noteform, type or use Dragon to input information to update if needed
Active Problems – Review and update. A designation of one active problem or no active problems
must be entered to meet MU.
Histories – Review PMH and activate any current problems (change status to > active), Collect/verify
PSH, Fam Hx
Vitals – Review as necessary
Reference Documentation (PRN) – Check box in EMR Reference Documentation for visits requiring
additional paper documentation (Patient Intake Form)
 Patient intake form if going to be scanned into aEMR.
 Additional Scales and Forms that are on paper will be scanned in.
PE – Use noteform, type, or Dragon to input information
Results/Data – Review labs. Pull in previous results using the “Advanced result citation” feature PRN
Drawings – All drawings completed by patients must be stored in shadow chart or in outside storage.
Can’t be scanned into aEMR.
MU Diagnoses/Problems – Select which active problems you are going to assess by checking a green
check on the notepad in front of the diagnosis and add new ones if necessary. Open Care guides/Qsets
from this area to add orders. ***
MU Orders – Order Rx, Labs, DI, Procedures, Referrals, Education PRN
Can order using problem based orders--Care guides
Referrals entered via the Orders section
 Routine for central scheduling* (Most common way to schedule/defaulted)
 Use Stat for secretary scheduling
 Specify referral reason by selecting second radio button and free text reason for
referral.
MU Patient Instructions – Indicate how patient education was given via the ACI screen
Provider Impressions – Enter notes specific to your care that are for your reference PRN. These will
not display on the clinical summary.
 You can also dictate a provider’s name you want a referring consult letter to be
sent.
Patient Discussion/Summary – Enter information you want to share with the patient on Clinical
Summary.
Follow-up visits - Notate when you would like the patient to return for their follow up visit. ***
Indicate follow-up in patient discussion summary. Can be entered in by typing, dictation, or dragon
Published date 6.3.2013
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Goldenberg
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Billing
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template
Consult Letter/Referral Letter
 Send consult/referral letter electronically by first checking the Referral-Consult
Letter box and then clicking the Carbon-Copy button
 Select the resident who sent the intial referral letter.
 This will drop to all residents in that particular group.
Sign/Finalize Note
Save and Close – Use the Save and Close button to save your changes
Status – Use ‘Orders Pending’ patient status to alert RN that her assistance is needed or change
status to ‘Visit Complete’ PRN
Printing – Requisitions or controlled medications will print upon saving; Also, print any education
materials and give to patient PRN
MU Clinical Summary – Print and send patient to checkout. Front desk will hand to patient.
 NOTE: You are able to edit the clinical summary before printing by clicking on ‘Edit
Clinical Summary’ and selecting certain sections that you want displayed in this
document
If provider needs to write secure comments or notes, the provider will open second
encounter/note.
 Create a Psych Communication Note
Physician
Sign – Press the Sign button to sign and finalize the visit note
Charges: Fill out paper charge ticket
Patient Leaving
Can only bill case if patient is seen by MD provider
Patient Left - Patient Encounter Complete
Between Patients:
End of Day:
All
 Review My Active Tasks for tasks that are assigned to you
Secretaries  Print out daily Rx report from task list for physician to sign. Scan signed document into file cabinet in
Scan.
 Check the Print queue for successfully eRx/faxed Rxs
 Send referral/consult letters to associated provider on account.
 Scan any additional documents that the provider has flagged on chart.
Goldenberg  Review Worklist tab for your incoming results and Rx refill requests. ‘Verify’ and/or ‘Authorize’ and task
to clinicians as needed.
 Review Worklist tab for physicians that you are covering. Sort by abnormal to review those results as
needed. Create an addendum for results if you take action, but do not verify them so they remain in the
ordering providers’ queue for review upon their return. PRN
 Covering Providers will only look at urgent items on an out of office provider’s work list. Filter urgent by
selecting the (!).
 Physicians will utilize verify option on any outstanding work list items. Nurse and covering provider will
only annotate on open work list items.
 Document Telephone Encounters
 Open Note->Communication->Psych Patient Communication
 Sign Note if no additional follow-up is needed.
**If telephone encounter is not pre-scheduled; note will be created and an encounter will be linked
retrospectively once an appointment is created in Athena.**
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MU refers to the items that are important for Meaningful Use stage 1 requirement. Please refer to the meaningful use
handout for additional information about the specific guidelines and percentages required.
Published date 6.3.2013