Alright Leslie works for me. Its a lot different for a new patient versus a follow-up. So let's start with a new patient that will need an operation.
New patient with gallstones
1. Checks in and my front office person asks for their drivers license and insurance card (most times we know the insurance beforehand from my referring docs). Those are scanned in.
2. Give the patient the history questionnaire, demographics sheet, and HIPPA/Financial forms
3. Copays collected
4. Patients pre-printed superbill from my PM system as well as their history questionnaire are placed on a clipboard
5. Patient gets vitals (which are just jotted down on the history questionnaire so I'll have them in front of me) and then roomed
6. I see the patient, plan surgery and mark on the paper superbill
7. Fill out a form for pre-op orders (on paper) that are faxed to the hospital
8. Other Front office girl (I have 2) schedules the procedure and gives the patient a pre-op sheet (what time to show up, NPO, blah, blah)
9. While I'm in the room, the demographic info is entered (time permitting) or rechecked if we have that info from before
10. I hand the history questionnaire to my front office girl for later. She enters in all of the vital signs, Allergies, medications, PMHx, PSHx, and review of systems into AC and forwards the chart to me (usually this doesn't get done until after clinic). I fill out the HPI, PE, A/P, create a letter to my referring doc, and fax a copy of the H&P to the hospital, which is usually that afternoon or the next morning.
Follow-up or post-op patient
They walk in the door and tell my front office girl their name. She grabs the pre-printed superbill and rooms them. Rarely do I repeat vitals unless there was something markedly abnormal before (because I don't adjust meds for blood pressure or pulse, I just need them for pre-op). Occasionally I'll get a weight but not routinely. I see them and mark on their superbill their f/u if needed and give it to my front desk person.
Any suggestions? I know I'm essentially just using AC for documentation. My hospital wants labs on a certain triplicate paper so using orders in AC is a rarity. They also want radiology orders on a different sheet. I wanted to send all of those items to the hospital through AC initially but that ended up being more of a pain than just filling out their stupid sheets. I'm working on that though so I can avoid some of the paperwork.
I would say my most common prescription is pain medication and if Schedule 2, must be written on Rx pads. Otherwise I try to send them by e-fax/e-Rx
