I do not have any amazing new discoveries about using the EMR, but would just like to recommend some housekeeping things and some reminders:
1) Now that all but new patients have their chronic diagnoses codes in the system, it's time to do some housework--some of the diagnoses are incorrect, and some problems in the chronic problem list need to be resolved--or put in the past medical history list.
I find the best way to do this is to go to the problem list in the hub and pick "remove/ and add to Past Medical history".
2) When seeing a follow up patient--you must always check NKDA if no allergies have been added. This is a safety feature.
3) Check to see if surgical, hospitalizations and family history have been entered, and update them.
4) When seeing a patient there are 4 places that are very helpful to check-:
--Referrals (have any been done that the patient is waiting for?)
--Patient Docs (have any labs, radiology, consultants notes been added?)
--Alerts--Are any recurring items due?
--Immunizations--has the patient had pneumovax if indicated? do other immunizations recommended for this patient need to be recommended for the patient to obtain at the health department?
5) At every visit check to see if the tobacco, alcohol, and drug history have been added.
6) Document every contact outside of a visit, refill, care coordination work in a message (called New telephone encounter in eClinical) . Medications can be ordered, and updated from the message window.
7) Continue to document contraception status if the patient is in the reproductive age.
