Home Forums Discussions Problems how to optimize workflow giving immunizations

I am a pediatrician new to AC. I am trying to figure out the best way to manage the workflow when giving shots. I suppose my ma will take the patient back for vitals, etc. Then, I suppose she will forward the chart to me. Now, after I see the patient and fill in my documentation, and assessment, etc ..... I want my ma to give immunizations. I can see different ways to get this done, but there has to be a best way. (Do I do this through the order button, through the message button, do i make a note in the assessment, then do I forward the chart back to the ma???) Helpful advise would be much appreciated. Thanks, R Sag, md

I have been using the program now for around 7 years with the exact same workflow. If you buy into my two "tenets" I think you will find the best way to do this quickly.

#1 A good workflow requires the absolute minimum of messages and forwarding of charts including these orders.

(First thing I did with v5) was get rid of any orders to MAs). They would be great if my MAs just sat in front of their computer screens all day but, in reality, they don't. So, seeing a patient, and then sending orders to the MA that then has to refresh her inbox constantly does not some like a good flow. I also think that forwarding a chart to anyone is counterproductive. It should be forwarded to you by the MA for your use. You can forward it back to yourself, but that is it.

#3 Give up your control. Delegate not medical responsibility. Anything like immunizations can be taught. If you really want this to flow, let you MA choose the shots. I know all the rules, but I can tell you my MA knows them better. The quirky rules I will always know better, AND I always look at her selections.

So, basically, in my office, my MA grabs the chart and takes it to the triage area. She brings up a new note and enters some patient data, brings back the patient and triages. It is a 15 month wcc, so she figures out the vaccines and goes over them with the VIS, etc. They agree to the vaccines, she checks them off on the Superbill and in the EPDST. If the patient needs four shots, and they only want two, she will often, circle those then put follow up times at the bottom of the Superbill with the one month follow up times over and above my bringing them back. She has templates for those who refuse or only want half and lists the ones they will be returning for.

When I get the chart, I can see at a glance that she has circled the ones they are getting, and has Xd through the ones they require, but are refusing/putting off. Now, of course, it is here that I make the final decision. But, if after seeing the patient, I just put the chart up on the door and put up the red flag, the nurse knows she can give the shots (she has already drawn up), because she is correct 99% of the time. There are times the parents aren't sure, and she leaves everything blank or there are times I must change things.

In all of this there is the forgotten art besides computer and paper of actual communication. MA stops me in the hall and says, "They are fine with the MMR, they just don't understand the Varivax."

It is my strong opinion, especially if you have one major MA, that by

1. Teaching them the vaccine schedules
2. Allowing them to use the various catch up schedules, etc.
3. Teaching them the many subscripts at the bottom of the schedules with the special instructions
4. Let them do them

they will be able to handle > 99% of your vaccines entry. If you think about it, they are the ones ordering it, talking to you state, changing the expiration dates, etc., entering all the vaccines, doing your VIS, meeting with the state, etc. They are immersed in this stuff. Let them do it.

If you could put your first name in a signature, that would be great. Also, you could look at VIPER, an interface program to AC.

Thank you Bert. I am so glad that I do not need to do all these formal orders and messages.
Could you clarify what or where the MA would use the templates when patients refuse or want to delay some of the shots. and where it would show up in the record.
When you write: "has Xd through the ones they require, but are refusing/putting off" do you mean the paper super bill.
Also along the same vein, for someone with a sore throat and a fever, etc, do you have your MA do a throat swab, and if so where would she write that it was done.
In my office I have my MA who performs a tympanogram before I see a patient with a chief complaint of an earache. Again does she and where does she enter that she has done this; and do I then scan - import the printout?
I will look it up, but what is "viper"
Thanks
Richard
pediatrician
Orlando

Hi Richard,

Don't forget you can make an automtic signature as well, and it will be quicker.

Pretty much anything that my MA documents in the chart along those lines goes in the HPI. I want to know first thing if a)a shot has been deferred or questioned, b) a strep test is pending or c) the parent refused the strep test or d) Strep test indicated, but patient wanted exam first (or also has ear pain....). I ALWAYS read the HPI from my nurse as I consider her history and input invaluable.

We don't do tympanograms as of yet, but if we did, we would scan that in.

We also charge for the Strep test, so she circles that a strep test was done. If the result is back, she enters that as well, but we use instant messaging, so I generally get the answer in the room anyway.

For VIPER info, see private message.

Hello Bert,

Automatic signatures are used for reports,... Is that what you mean?

Instant messaging as a tool. Is this through AC, if so - how.
If not through AC, how do you use it - and what needs to be documented in the record - or is it just like a talk in the hall?

Thanks

Richard
pediatrician
Orlando

Sorry about the confusion. If you set up a signature in your profile, then it will automatically show up as:

_____________
Richard
Pediatrician
Orlando

or whatever you put in. It's just easier than typing it everytime, and it is much more pleasant to reply to a "Richard" than an "rsag." Usernames can be changed as well if you wish.

We have intranet instant messages using the defacto best IM program for networks by ipmsg. It is is by far, the best, and I have a Word document on the best formatting. AC's messaging system is great for longer term things but is inadequate for real time messaging as it a) makes no noise and b) doesn't auto refresh.

Do you use the intranet IM to communicate with the front office too?
What kind of workflow communication activities do you use with IM, and when do you decide to use AC messaging to document communication to the chart?
This all seems so simple, I know. I really appreciate your feedback

Well, all patient messages would go to AC inbox. So, my front staff sends an AC messsage to my MA that Johnny has a fever. She sends it to me or takes care of it and copies me, etc. All charts are like messages. Pretty much anything that needs to be saved to the chart and can use the advantages of having the PN and Med writer attached.

But, there are so many messages that normally would have to be done by walking down the hall and interfering with the visit. Say, I am in a room, and I need to speak to Dr. D, the endocrinologist. I just message my receptionist. Many times, she will message back he is on line 1. I can take the call right there. Otherwise, she may message me that so and so is on the phone, and I can tell her I will call her back. Another message may be an urgent read, etc. All of these are logged. And, since messages can be sent to all rooms, you can send to more than one room or person. They really are invaluable and pretty much anything you would use AC for would not work well for IM and vice versa.

I see you got your sig. You learn quickly.

What is the PN?

The med writer is for writing prescriptions, right?

Thanks again

Oh, sorry. PN = Progress Note.

Med writer is the prescription writer.

Thank you Bert.

I've got my homework

No problem. I am a tough grader, though.

After reviewing the thread from yesterday, I have a question about the chart.
When you wrote:

"...When I get the chart, I can see at a glance that she has circled the ones they are getting, and has Xd through the ones they require, but are refusing/putting off. Now, of course, it is here that I make the final decision. But, if after seeing the patient, I just put the chart up on the door..."

Are you referring to a paper chart, a paper encounter, a paper superbill, a paper worksheet or something else?

I am trying to figure out as I do my transition from paper charts to AC, just what the role of my old paper charts will be, and / or will there be a role to continue paper charts for new information?

Oh, sorry. I was referring to the Superbill. I am not sure how things will change with the new PM, but we use a separate billing program, and the billing portion in AC currently is not conducive to our work flow.

We use very little paper, but we still use the Superbill. I also tried using the orders for F/Us for my front desk for awhile. It makes sense, but since I usually walk to the front desk with the Superbill, it was just one extra step.