EMR Work Flow KNIGHTS Clinic at Grace Medical Home

Logging in for the FIRST time Username and password- Username is first initial and last name with first initial and first letter of last name capitalized (ex. John Smith – JSmith) Password: Temporary password is “password” ** you will be asked to change this eventually** Open 3 tabs: Click on Run in the upper left and open: ChartView Schedule Tracker You will not have to do this step again!

To review patient history Go to schedule, find your patient, right click and select “Launch Chart” From there, choose health summary (upper left side) and you can scroll through the categories

Once the patient has checked in by the front desk... Placing a patient in a room When you are ready to bring the patient back - go to the tracker, and move patient to the correct room (remember, you need to select the physician you are working with in order for the patient to pop up on the left “in the waiting room”) This is your first important time marker!!

Once patient is in the correct room, click on their name again on the tracking board and click “collect vitals” (this will open the patient’s chart) ***this is your second important time marker!!***

“Reminders” When first opening a patient chart click “Reminders” on the tool bar Reminders will then appear on the side of the screen If a reminder is addressed during the visit it needs to be removed manually by clicking the red “remove” sign When first opening a patient chart at the bottom of the home screen will be a list of rules. Click “Run All” to refresh the list (NOT “Refresh”) These rules are important items that need to be addressed with the pt during their visit When the rules are addressed and properly documented they will automatically be removed from the list

Starting a New Doctor’s Note To start your new Doctors Note- click on the piece of paper and select “Doctors Note” Select your attending physician as “Health Care Professional” and yourself (student) as “Assistant”

Ok, I’ve seen the patient. Now what? Take a few minutes to discuss, talk to Patient Education, then present to attending physician ***if you feel comfortable, begin filling out electronic document while speaking with attending physician*** The next step is to see the patient one last time with your attending

Seeing the patient with an attending ***REMEMBER- go back to tracker, right click on patient name and select “With Physician” ***this is your third important time marker!!*** Confirm plan with the attending- including any labs, medication, or procedures that need to occur before the patient leaves **DO NOT ENTER ANY LABS WITHOUT CONFIRMING WITH THE ATTENDING**

Filling out the Electronic Note First, choose your CC (Chief Complaint) Once you have a chief complaint, you can now skip down to the plan ** Remember to ALWAYS CHOOSE “Grace General Medical Plan” From there, you can specify what needs to be done with your patient. Once you have entered all information, the lab/pharmacy etc can do their job so the patient can leave ASAP ** don’t forget to enter patient education information— patient education should give you the handouts they gave the patient so you can select the correct information—this is under the “plan” section of the document

Doctor’s Note- Chief Complaint

Doctor’s Note- Plan

Filling out the Electronic Note Now, go back and fill in the rest of your document  Vitals, Physical Exam, ROS etc. ** remember, if patient has been here before, all PMH/Meds/Allergies etc should be on the left hand side— **verify this information with the patient, add or delete as necessary and make sure to click “Reviewed” for each box. This information can now be transferred over to your document by using the small arrow tabs next to the abbreviated category names on the left hand side of your document- Click on the arrow and on the drop down box click add! *** if you change anything on the left after adding to your document, remember to just click “Refresh” and your document will be updated.

Filling out the Electronic Note- Vitals

Health Summary-Allergies

Health Summary- Medications

Adding Vitals and Items from the Health Summary to the Doctors note

Doctor’s Note- HPI

Doctor’s Note- ROS

Doctor’s Note- Exam

Doctor’s Note- Assessment

When can my patient leave? After everything has been completed for your patient (labs, prescriptions, referrals) and instructions have been given to your patient— YOUR PATIENT CAN LEAVE! – even if you’re not done with your document. ** remember, our priority is to provide the best care possible in a reasonable amount of time

Do I have to ‘check out’ my patient? When patient is cleared to leave—go to tracker, click on patient and select “check out” ***this is your fourth important time marker!!*** ** don’t forget the check-out sheets on the back of the door  fill out the information and give to your patient so they can check out

I think I’m done with my note. Now what? ** don’t forget the check-out sheets on the back of the door  fill out the information and give to your patient so they can check out Once happy with your document, tell the attending physician so they can review it—STUDENTS DO NOT NEED TO SIGN THE DOCUMENT- The attending physician will take care of signing and closing the document. Remember, when logging out ALWAYS CLICK THE KEY SYMBOL.

For Physicians: Signing off the Note

Key Points to Remember… TRACKING Pt. will be listed in waiting room, left click to assign them to a room “in room” On tracking board left click on patient again and click “collect vitals” (this opens the pt’s chart) Once you have completed filling out the chart click the gold key to log off After you have collaborated with your attending and the attending is ready to enter the room go to tracking board again. Left click on the patient and click “physician provider start” When is pt is ready to leave select “check out”

Key Points to Remember… CLINIC FLOW Student pairs will interview patient and perform physical exam Student pairs will review their findings and notify patient education to enter the room while presenting to their attending Student pairs will discuss a plan with the attending physician and then see the patient again with the physician. Student pairs will notify the lab if there are any labs to drawn Student pairs will notify pharmacy if they plan on prescribing any medications

Thank You for Choosing to Volunteer with the KNIGHTS Clinic at Grace Medical Home