LibreHealth EHR Encounters

From LibreHealth EHR Wiki
Jump to: navigation, search

LibreHealth EHR Encounters

Introduction

The purpose of this document is to create a generic encounter within the LibreHealth electronic health records system and showcase the basic workflow.

We will create a very simple scenario that uses default access permissions for the different staff roles.

In this document, encounters may be called visits or referred to as patient visits.

We will see how the Front Desk and Nurse’s Station operates. We will also follow the doctor in creating notes and orders, and see how they are followed through.

We will then look at the final Report to see how the LibreHealth EHR system tracks each step within the patient’s visit.

Note: Patient and staff names or any data you may see are completely fictional.

Toni Shortsleeve, LibreHealth Documentation Intern, July 22, 2018

The Encounter Workflow

Doctor offices differ widely in the tasks that occur and who is allowed to do which tasks.

By default in LibreHealth EHR, a clinician such as an LPN will not be allowed to edit medication orders or to see any other staffs encounter notes. As in this case, those with Administrative access privilege can give the LPN permission to access these areas.

The high-level flow of this encounter is as follows:

  1. The Front Desk checks in the patient and assigns an exam room
  2. The Clinician takes the Vital Signs
  3. The Provider performs a Review of Systems, documents the visit with a SOAP note, and records the services on the fee sheet
  4. The Provider orders medications
  5. A medication-certified staff member - or LPN - administers the medication and documents the activity
  6. The Front Desk takes a payment and checks the patient out of the appointment
  7. The Facility Manager or Administrator reviews the Flow Board Report

LibreHealth’s Accountability and Auditing functions associated activities with the user who is logged in on the computer where the activity occurs. It is most convenient for each participant in the workflow to have their own computer logged in to the EHR system where they each do their work.

However, if staff members are sharing a computer they must absolutely learn to log into LibreHealth, do their work and then log out. This leaves the computer for the next person to log in, do their work and log out.

We’ll begin with the patient’s arrival.


Patient Arrival

Tina Chan is the Front Office staff member at the South West Practice.

She is logged in to LibreHealth EHR.

Tchan.jpg



Tina has the Calendar and Flow Board opened for today’s events. Hovering over the patient name in the calendar shows that the 9:00 am appointment is a new patient. Knowing this allows Tina to have the initial paperwork prepared.

Tchan-flow-cal.jpg

Sarah Johnson arrives fifteen minutes early so that she can fill out new patient paperwork. After Tina has given the patient the paperwork, she will click on the Status (- None) for the patient in the Flow Board. This will pop open a new screen.

Tchan-flow-status.jpg

By choosing None in the Status column, a Change Status menu will popup. Tina selects @Arrived to show that the patient has arrived.

Many of these choices are default in the LibreHealth EHR. They can be changed to meet your practice needs and may say something a little different on your system.

Tchan-arrived.jpg

Tina can now choose an available Exam Room. She has chosen Room Number 2.



Tchan-room.jpg

The Flow Board has updated to reflect the current status as arrived, in Room 2.

Each Provider can only see their own appointments. However, the Front Office staff sees all the provider’s information on the Flow Board.



Thcan-arrived-flow-stat.jpg

The patient is taken down the hall to the Nurse’s Station and greeted by Dana Evans, the LPN.

Dana-evans.jpg

Patient Vitals

Dana must click on the patient’s name from the Patient Finder. This will open the Patient’s Record.

Notice there are three patients with the last name of Johnson. Jenny and her twin daughters, Jessica and Sarah, are patients at the South West Practice.

Be cautious when choosing the actual patient from the Patient Finder. Make certain that both the name and the birth date matches.

Dana-finder.jpg

Dana has opened the patient’s record. Each appointment gets its own New Encounter. The list of past encounters is there in case you need to look at them.

Dana will choose to create and save a New Encounter. This will open a new Encounter screen.

Dana-new-enc.jpg

From the Encounter menu, Dana will click on Clinical. From the Clinical drop-down menu, Dana will then click on Vitals.

This will open the Vitals screen and allow her to add the patient’s vitals to the Encounter Form.

Dana-vitals-drop.jpg

Dana will enter the vitals information and choose to Save Form.

Dana-vitals-input.jpg

The Encounter Form now shows the patient vital signs at the beginning of this visit.

Dana-vitals-enc.jpg

If Dana does anything else, such as taking a patient’s statement, then Dana could also create a SOAP Note.

Once the chart entries are complete, Dana should digitally sign them. This locks them to prevent modification.

Dana would choose the eSign button and see the new popup.

Dana-vitals-esign.jpg

Dana will enter her password and then click on the Sign button.

Dana-vitals-sign.jpg

The Vitals section of the Encounter Form is now signed, dated and locked.

Dana-vitals-locked.jpg

Dana returns to the Flow Board and changes the status to < In exam room. This lets the Provider know that the patient is ready to be seen.



Dana-in-exam-status.jpg

Then Dana escorts the patient down the hall to Exam Room 2.

The Flow Board now shows that the Patient is in the exam room.

Dana-flow-inroom.jpg

The Patient Exam

Dr. Apgar is sitting at the computer in Exam Room 2 with the Patient Record open.

Vapgar-exam-room.jpg

Review of Systems

Dr. Apgar will conduct a Review of Systems.

On the Encounter Summary menu, she will choose the Clinical menu group.

From the Clinical drop-down, she will choose Review of Systems.

Vapgar-ros-drop.jpg


This will bring up a new screen that will evaluate various aspects of the current patient situation.



Vapgar-ros.jpg

Once the Review of Systems is saved, it will be shown on the Encounter Form.

Vapgar-ros-enc.jpg

SOAP

During the exam the patient complained of lower back pain.

Dr. Apgar will create a SOAP Note by clicking on Clinical from the Encounter menu.

Then she will click on SOAP from the Clinical drop-down list.

This will open the SOAP Notes screen.

Vapgar-soapdrop.jpg

Subjective is what the patient says.

Objective is the practitioner’s observations during the visit.

Assessment is the provider’s statement of what the problem is.

Plan is what the provider wants to do for this situation - mention any medication to be ordered or any actions to be followed.



Vapgar-enc-soapnote.jpg


Always remember to click the Save Form button.

Fee Sheet

Dr. Apgar will document the visit for billing purposes.

From the Encounter menu, she will click on Administrative.

From the Administrative drop-down menu, she will click on Fee Sheet.

Vapgar-fee-sheet.jpg

Sarah Johnson is a New Patient. So Dr. Vapgar will click on Detailed from the New Patient drop-down choices.

Notice the Type Code automatically entered the CPT4 code associated with a new patient.

Vapgar-new-det-fee.jpg

Dr. Apgar will enter the price for the visit. Then she will choose to search the ICD10 Diagnosis code for low back pain.

Vapgar-visit-icd10.jpg

Dr. Apgar will choose the Search Results dropdown of the IDC10 code of M54.5 for Low back pain.

This will drop the IDC10 code onto the Fee Sheet.

Vapgar-visit-fee-code.jpg

Inside the CPT4 code is the Justify drop-down list.

Dr. Apgar will choose the ICD10 code of M54.5 from that drop-down.

This will justify the visit for outside insurance or billing purposes.

Vapgar-justify-visit.jpg

Now Dr. Apgar can save the Fee Sheet.

Vapgar-visit-fee-save.jpg

Status Change

Now that Dr. Apgar has completed the visit, she needs to let the Flow Board know that there is still one thing to do before the patient can leave.

She will change the current status of the Flow Board from In Exam Room to | Requires Action.

This is a customized Status Type preferred by this facility for communicating that something must occur by another staff member, such as administering medication, before the patient can be Checked Out.

Vapgar-action.jpg

Medication

Dana has seen the updated Flow Board, and knows that she must return to the Encounter Form to see what is needed to be done.

Dana-flow-action.jpg

Dana returns to the Encounter screen to see a medical order in the Plan section of the SOAP note.

Dana-med.jpg

At the Patient Encounter screen, Dana confirmed that no prescription has been filled yet.

When Dana clicked to Edit the Prescription tab, a new Add Prescription screen opened.

Dana-presc-none.jpg

Prescription

First Dana must enter the name of the medicine and click to search.



Dana-presc-add-drug.jpg


The trade name will be shown in the search box.



Dana-presc-drug-drop.jpg


Choose Select on the drug’s trade name, and that medicine will be ordered.



Dana-presc-drug-select.jpg


Manually enter the Quantity, Medical Units and additional information.

Dana-presc-drug-add-units.jpg


Check Yes to add to the Medicine List.
We do not want to substitute this medication.



Dana-presc-add-no-sub.jpg


Choose to dispense this 1 unit as described above.

Enter the cost of this prescription.

Choose Save and Dispense.



Dana-presc-add-price.jpg


A new screen with show that the prescription has been prepared.



Dana-presc-done.jpg


Sarah Johnson now has a prescription order for Robaxin in her health record.



Dana-presc-new.jpg


Add to Fee Sheet

Dana opens the current Fee Sheet.



Dana-fee-sheet-open.jpg

Dana will search CPT4 Procedure Service for injection.

Dana-fee-inject-search-rect.jpg

A drop-down menu will show the CPT4 code for “injection”.

Dana-fee-inject-drop.jpg

Once the search field is chosen, the Fee Sheet will update with the new information.

Dana-fee-inject-cpt.jpg

Dana will now search for the HCPCS code of the prescribed medication.

Dana-fee-hcpcs-search.jpg


A drop-down menu will show the HCPCS code for “Methocarbamol”.

Dana-fee-hcpcs-drop.jpg

The Fee Sheet has updated with the HCPCS code.

The price is included based on the information already in the system. If the cost is not in the system, it will need to be added manually.

Notice the NDC code is not needed for Cash Only patients. It is used for insurance billing purposes only.



Dana-fee-hcpcs-nds.jpg

The Fee Sheet now has all of the information needed, and each code is justified for this particular ICD10 coded procedure.

Remember to Save.



Dana-fee-all-codes.jpg

Dana will give Sarah the requested medication. Now it must be documented that this has occurred.


Documentation

Returning to the Patient’s Summary Screen, Dana will expand the Prescription tab and click on the prescription name.

Clicking on Edit will re-open the Prescription screen.



Presc-confirmed.jpg

Dana will unclick the Currently Active checkbox.

In the Notes textbox, Dana will note it was “given by Dana Evans” and Save the form.

Prescription-given.jpg

Returning to the Patient Summary Screen, Dana will now expand the Medicines tab.

Patient-med.jpg


The new Medications screen shows the current Medication ordered. The Status is Active and it needs to be De-Activated because the medicine has been administered.

Med-deactive.jpg


Dana will change the End Date to the date of the medication administration.

Dana will add the Comments: given by Dana Evans.

Then Dana will change the Outcome to Resolved.

As always - remember to Save the Screen you are on.

Med-outcome.jpg


Now the Medications Tab shows the Status is Resolved and no longer Active.

Med-done.jpg

Dana will create a new SOAP Note. In the Plan section she will document her actions.

Dana-soap-med.jpg

Dana will return to the Flow Board and select Chart Pulled and remove the Room number from the list.

Status-chart-pulled.jpg


Dana will then walk the patient back to Tina at the Front Desk.

Flow-chart-pulled.jpg


Checkout

Tina will click on Fees from the main menu for today’s Encounter.

On the Fees drop-down, she will click on Checkout.

Tina-fees-checkout.jpg

This will open the Patient Checkout Screen for Sarah Johnson.

Both Fees have carried over to the Checkout screen.

The Amount Paid is default as total amount to be Paid in Full. Be certain to change this if it is only a partial payment.

Tina-checkout.jpg

The Payment Method of Cash is the preferred method of payment for many cash-based clinics.

If the payment is by check, then choose Check Payment from the Payment Method dropdown menu and enter the Check Number in the text box below.

Tina-checkout-pay.jpg

Now the Receipt can be printed as it is.

Tina-reciept.jpg

The Receipt can also show the details of the charges to include the Injection.



Tina-receipt-details.jpg

Now Tina can use the Flow Board to change the Status to Checked out.



Tina-status-checkout.jpg

Tina can also use the Calendar to change the Status. However in this practice, the Flow Board is preferred for Status changes.



Tina-cal-check.jpg

Flow Board Report

The Flow Board is a great help for staff to communicate on where the patient is within the appointment. The Flow Board also generates a report on the data it collects to assist in monitoring Practice performance and other uses.

This report can be run daily, weekly or monthly depending on the practice needs. Usually this is run by the practice manager or administrator.

For the purpose of this document, the Facility Manager will run the report on this patient near the end of the day.



Admin-fac.jpg

From the top Menu, the Facility Manager will click on Reports.

From the Reports drop-down, she will choose the Visits sub-menu.

From the Visits drop-down, she will choose Patient Flow Board. This will open a new screen.



Admin-flow-drop.jpg


She will choose the South West Practice as the Facility and Dr. Apgar as the provider.



Admin-flow-dr.jpg


The From date should be the date of encounter. The To date can be the following day to assure all the information is viewed.

Clicking on Submit will drop down a list of patients who fit the chosen parameters.



Admin-flow-total.jpg


Check on Show Details and click Submit to see the entire flow of the visit.



Admin-flow-details.jpg

Now we have the detailed Flow Board report for the visit.

We can see the time each Status Change occurred and how much time was spent at each segment of the patient’s visit.

Summary

We have met the staff members of the South West Practice.

We have followed a patient from the arrival to the checkout, and seen how the doctor, nurse and front desk work with the patient.

And we have seen how the LibreHealth EHR Flow Board tracks and reports the entire encounter.

We hope this guide has been helpful in preparing for your future encounters.