Procedures/Labs/Supplies

Please pay particular attention to the following areas:
1. All staff should order labs in the LAB ORDERS Tab to receive Meaningful Use credit. Certain clinical staff should be given authorization to input results in the EMR. If the results are simply scanned in, again, this will not qualify for Meaningful Use.
2. In the MEDICATIONS Tab please use the following:
IV HYDRATION: Make sure you complete this pop-up completely. The time of start/stop or total time of IV is required for billing purposes.
ADMINISTER NEBULIZER TREATMENT: Complete this pop-up completely (except no need to do full VS, just the Pulse Ox) There is no need to order medications extra...this is included in the pop-up choices.
3. In the TESTS Tab, choose Spirometry and complete this pop-up when you perform this test.
4. SKIN PROCEDURES: LACERATION REPAIR: Complete this pop-up completely. Note especially that you must enter the laceration LENGTH for billing. No need to add additional orders for Lidocaine or Neosporin. But, if you only apply Steri-Strips, you should not choose this as laceration repair,,,but rather under the SUPPLIES Tab.
8. PROGRESS LOG: The Callbacks and Messages should be put in the Notes here by the Clinical staff or Providers.
9. A&P: It is a good idea to use ICD9Data.com to search for particular diagnoses or codes that one cannot find easily in Velocidoc. (I usually keep it running in the background on my computer.)
10. FLU SHOTS: These are entered by Registration in 1 of 2 options: If the patient is a self-pay, the chart will be a Quick Visit and will be inaccessible to Clinical staff or Providers. The Clinical staff should complete a Flu Shot Form and scan into the Demographics. You need do nothing further in the back. If the patient will be charging the Flu shot to insurance, this will be a regular chart. Clinical staff need only do Height, Weight, BP and Temp, then enter the Flu shot info in the Procedures/Labs/Supplies tab as usual. The Provider will need to simply discharge the patient with the diagnosis code V04.81 and select COMPLETED CHART at discharge. Again, the rationale is related to Meaningful Use compliance.

Tiffany says that it would be very helpful if we state in the discharge summary if we have discussed lab results with the patient and which ones. Or make sure we put a note in the chart if we do it later.

That works unless the labs come back after the patient has been D/C'd. In that case there would need to be an addendum until we find out a better answer from PV. I don't like the idea of leaving a chart open unless we are waiting for a stat lab.