Office Visit Entry Screen

Transcription

1 Office Visit Entry Screen Verify correct student, school year, date, check in/out times Profile/contact info enter Temperature, if taken Entity: campus Examined by: nurse or clinic assistant Notified: enter parent name, if called Note: details of assessment, interventions, treatments and disposition Visit Reasons: enter based on student complaint; student s enter with Student Check In kiosk nurse can edit reason; can enter multiple reasons Treatment: enter all applicable treatments/actions Dispositions: enter applicable disposition Waiting List: Add student and put them in Queue (quick entry with Time In and OV Reason) Keep In Office: use to hold student in Queue to finish documenting record later or after the student is released/picked up Release Student: completes office visit entry & releases student from Queue (can view/edit from Student Profile/Office Visit tab) Add Diabetes: opens Diabetes Care Log tab from within open OV Add Injury: opens Injury Care screen from within open OV Add Physical: RISD does not use; Physical is used to document AN screening Back: go back out of entire OV without saving; don t use back button to toggle between OV tabs 1

2 Administer medications to students through Sch Medication or PRN Medication tabs click Administer and complete details Office Visit Basics Add multiple, timed diabetes care events. Great for low BG visits! Links diabetes care with the office visit and adds the entries to both the Diabetes Care Log and Office Visit tabs in Student Profile Warning: Add Diabetes or Injury or Physical click Cancel button if you don t need it or a blank record will be added to the Student Profile Tab 2

3 Add Injury for urgent or emergent events (parent transport or EMS transport). Links injury entry to both the Office Visit and adds entry to both Injury and Office Visit tabs in Student Profile Office Visit Counts Show number of visits for all Reasons or Dispositions and/or by grade, class, teacher, all campus, etc. Great way to summarize clinic activity or show office visit trends for certain student populations. Ranges: Active students and all grades or select desired grade(s) Office Visit Ranges: select School Year and Visit Date (or date range) OV Codes: can unselect to refine your report (Flu visits, asthma visits, dispositions, etc.) Report Printing Options: select no additional printing options for a simple clinic visits by students list; add more printed detail, if desired Print Order: select to print most visits to least visits or least to most Page Break & Sort: by grade, by class, by teacher, etc. 3

4 4

5 Office Visit with Linked Health Records Office Visit reports with options to print details of linked records (medications, diabetes care, injury) Report Type Ranges: Active students and all grades or select desired grade(s) Office Visit Ranges: select School Year and Visit Date (or date range) OV Codes: can unselect to refine your report (Flu visits, asthma visits, dispositions, etc.) Report Printing Options: Linked Health Records offers more printing options than other Office Visit Reports Linked Records is the only OV report that gives total clinic visit time for each visit good information for ARD/504 meetings, attendance committee, or giving parents/teachers regarding amount of time student spends out of class 5

6 Office Visits by Student template Office Visit Basics Templates you create in this area work as Quick Print from Student Profile/Office Visit tab Name report Report Type: by Range (Active, select grades, activities) OR by Individual [add specific student(s)] Additional Student Ranges: select to Print student with OV, without OV or both Office Visit Ranges: select year, can select Exam Date if looking for a specific day or range of days Entered By: can use if looking for entries by a specific staff member Code Check Boxes: run report for all OV Codes or refine your report by selecting for specific Dispositions, Treatments, or Visit Reason Codes (uncheck and select desired codes) Report Printing Options: Add Page Break and Sorts, as desired Print School Year or Grade Print office Visit details: (notes, vital signs, assessments) Quick Print in Student Profile/Health records tabs: runs any report or report letter for just the student selected. 6

7 Office Visits by Date template 7

8 Diabetes Care Log report. Additional Ranges run by individual or by all active students with Diabetes Care Log 8

9 Office Visits with Linked Records Report. Report type: by Range or Individual. 9

10 SHARS-Medicaid Billing Office Visit Basics Fields Collected for billing: Last Name, First Name, Middle Initial, Birthdate; SSN, Student ID; Campus: Office Visit Date; Office Visit Time In; Office Visit Time Out; Office Visit Reason; Office Visit Treatment; Examined by; Administered by; Med Admin Date; Med Admin Time. Medications (billable by administration event) Use Medication Quick Entry or Enter through Student Profile (typically no time capture necessary) Admin by: MUST CHANGE TO THE PERSON WHO ADMINISTERED THE MEDICATION (teacher on field trip, office staff, clinic assistant, etc.) Procedures and Diabetes Care (billable by time) MUST DOCUMENT THROUGH AN OFFICE VISIT Enter procedures through an office visit; use visit reason (ex. ZSN Skilled Nursing Procedure) and appropriate Treatment Codes: GTF (tube feeding); GTS (tube site care); BGC (blood glucose check); PUM (insulin pump assistance); IOC (urinary cath); SCA (urinary self-cath) 10

11 From Sch Medication tab, document procedure Make sure the Administered by is the actual person performing the procedure/care For Diabetes care, add the diabetes care log; use appropriate Treatment Codes Scheduled Insulin should be given using the Sch Medication tab, the same as with a Procedure. 11