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Office Visit Flow General

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First Contact - The patient initially contacts the office which currently is done by calling or just walking in through the front door. This initial or "First Contact" begins the process of collecting information about the patient. Demographic information is collected first.

Telephone contact
In person, by walking in
A third proposed method - Online Registration

Check In (registration) - At arrival to the office patients check in to be seen by the practitioner. They register that they have arrived on a paper log at the front desk.

Verify Identity (2 Identifiers) - At registration it is very important to verify the identity of the patient. As practice size increases it is not unusual to have 2, 3, 4 patients with the same name. We have three patients with the same name two of whom are almost the same age, have similar medical problems and live in within a couple of miles of each other in the same postal code area.

Gather Demographics - Established patients have their demographic and insurance information verified. And updated. They are then invited to come into the back office from the lobby.

New patients complete a number of documents required by our federal government, a medical history from that asks for the “Chief Complaint” (the reason the patient wants to be seen), usually primary care physician, past medical problems, medications, allergies, surgeries, family (inheritable) disorders, social history (bad habits like smoking, drinking, high risk behavior, illegal drug use), and a “reveiw of systems.” HIPAA

Currently we are still printing a paper “routing form”. This is sometimes called a “router” or a “superbill” in different offices.

After coming from the lobby the patinet comes into an examination area and discusses the "chief complaint" and has their vitals signs measured and recorded. This is normally done in our office by a medical assistant. New patients have their “medical history form” reviewed and these medical problems, allergies, medications, surgeries, social history, family history are entered into the medical record by the assistant.

What I do next as a practitioner: In my office, review the medical problems, allergies, medications, and surgeries. Review the chief complaint and vitals signs. Review the social and family history. Look at the most recent encounter. Look at any labs and x-rays that were ordered at the last encounter. I start the next office visit note using "form_dictation". I may paste in the last office visit, or paste in a template. I then enter the room with the patient. I start up my conversation with the last encounter and ask about problems to see if they have resolve. I type the responses into PCs that are hard wired in the exam rooms as I am talking to the patient. If i am using the a last visit template i make sure and edit out anything that does not apply from the last visit.

I perform a physical exam limited to the problems that are being discussed.

I decide to order labs, xrays, or both (or neither). Inform the patient why I need these tests. I then exit the room. Currently these are being entered on a paper "routing slip".

The medical assistant returns and escorts the patient to the laboratory and/or x-ray.

The in house house labs are performed at this time and reported to the practitioner on paper. Reference laboratories are collected and prepared to by sent out to the reference lab. These orders, in our office, are enetered electronically using an encrypted connection with the lab company. Our reference lab runs MS Windows and uses Citrix ICAClient for this connection. The laboratory has other options available.

If the laboratory is not likely to be covered we are required to print out an Advanced Beneficiary Notice (ABN). This is signed by the patient who accepts financial responsibility if this is not covered by the insurance.

X-rays if ordered are performed. We went on digital x-ray last November. The assistant enters some demographics into the x-ray work station. This is a Konica-Minolta proprietary system running on a dedicated Windows workstation. This system has the ability to export the DICOM images to a DICOM server.

The x-rays are reviewed by the practitioner. (Many offices may have to send the patient out for x-rays).

We also have some other diagnostic machines that may be called in at this time: ECG machine, Spirogram etc.

The patient and the practitioner meet back in the examination room. A diagnosis is arrived at based on the available information. This is explained to the patient. This may require distributing printed materials to the patient information about the diagnosis.

Prescriptions are created written/printed/emailed/e-prescribed.

I complete my assessment and plan in the encounter note.

I generate the charges using CPT codes, match up each CPT code with an appropriate diagnosis ICD-9 code. Add any HCPCS charges (injections, splints, etc) with a matching ICD-9 code.

I then "authorize" the encounter filing it away for future work.

The patient proceeds checks out, making sure to pay any necessary copays or fees.

Scheduling Appointment - Primary Care patients schedule a follow up appointment. Urgent care patients are encouraged to follow up with there usual primary care office.

The next day, the laboratories are delivered electronically over the Citrix ICAClient and then printed out. I review my labs making comments about whether the values are abnormal or not and what we need to tell the patient about them. I also make notations about whether we need to change therapy. The medical assistants notify the patients of their laboratories. They then mail, fax or email copies to the pateints that want these. We also provide copies of our labs to as many specialists (also involved with the same patient) that we can. This is normally done by fax. Many times I personally review the printed labs with the patient in the office, sign off on the lab, have a clerk at the front scan this into the system and give the paper copy to the patient.

The flow of information in the laboratory is a lot like a relational database. Different types of information flow through the lab. More on this later.

Samuel T. Bowen, MD