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Blank Vital Sign Chart document sample
Document Sample
Health Center Score
Health Center Score
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Vendor 1 1-5 Vendor 2 1-5 Vendor 3 1-5
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Functionality
Planned/ Planned/ Planned/
comments comments comments
CLINICAL MANAGEMENT
Ability to enter all demographic and registration information in Practice
Management System and transfer it to EHR without any data entry
needed into EHR.
Ability to customize the patient demographic banner to display any
number of Practice Management System fields to the clinician.
Ability to switch from one patient record to another quickly and easily.
Able to organize the screen and customize tabs or modules according
to user preferences.
Ability to display a patient summary or “face” sheet including patient
demographics, problems, medications, allergies, health maintenance,
encounter listing, patient tasks, recent encounters, patient picture, and
personal profile.
Has problem list with most common problems available for each
physician.
Ability to add problems beyond an ICD-9 list to a recognized standard
nomenclature (e.g. SNOMED CT or MEDCIN).
Ability to display and manage health maintenance alerts, including
chronic disease reminders per patient.
Has medication list with formulary display.
Has allergy list including on-screen indicator of urgent reactions.
Do you have integration to an eHealth or patient online solution
allowing patient populations to verify their medical record, access billing
status, review tests results, and communicate to the physician?
Displays notification to provider of critical lab and other test results for
immediate attention with a prioritization alert.
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Problem lists, allergies, and medications can be updated or edited and
signed at any time.
Has standard order sets that can be customized by each provider
based on his/her favorites.
Has medical necessity and duplicate checking per orderable item.
Has ability to connect orders to a result for follow-up and reconciliation.
User can review and sign results for any ordered tests and procedures.
User can create test results letters.
Ability to send message and link to patient chart to additional non-
ordering providers regarding results documentation.
Allows providers to fax prescriptions to pharmacy using patient’s stored
pharmacy fax number.
System stores patients’ preferred pharmacy phone number, fax
number, and address.
Has prescription writing feature that records date, signature, number,
and directions.
Has plain paper prescription printing so that product is sufficient for
patient to take to pharmacy.
Gives alerts when prescription conflicts with documented allergy.
Gives alerts for drug-disease incompatibility (e.g., beta-blocker in
asthma)
Tracks drug interactions and displays alerts when conflicting
medication is documented.
Ability to automatically link prescription to the appropriate formulary.
Electronic transmission to pharmacies using fax and SCRIPT standard
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Vendor 1 1-5 Vendor 2 1-5 Vendor 3 1-5
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Functionality
Planned/ Planned/ Planned/
comments comments comments
Automatically checks for coverage and eligibility through RxHub or
something similar
Ability to download medication history from RxHub to identify
duplication medications and potential interactions.
Tracking of patients using specified medications.
Tracking of drug formularies from insurance companies (provide list of
carriers and how formularies are initially provided and subsequently
updated).
Ability to customize formularies.
Ability to search and report on prescribed medications in case of a drug
recall.
Cost analysis of prescribed medications in comparison to formulary and
generics.
Maintains medication lists in different list for historical and current.
Ability to provide alternative suggestions for medications.
Have lists of providers’ most prescribed medications and dosages.
Ability to perform patient population queries for decision support.
CLINICAL DOCUMENTATION
Has a Web-based patient interviewing software that can be
incorporated into a note.
Has the ability to insert dictation markers into note for insertion of
transcription. Allow providers to build a note with a combination of
structured data and transcription.
Ability to capture dictation on a mobile device on an online or offline
mode.
Has option to dictate while navigating through the chart.
Has dictation management system with intelligent routing and tracking
of the status of each dictation job.
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Functionality
Planned/ Planned/ Planned/
comments comments comments
Has an integrated transcription solution with macros, carbon copy and
distribution features, and full line-count reporting.
Has ability to transfer MxSecure Transcription records into EMR
product for Providers to access, and sign off
Ability to go paperless.
Has a scanning solution integrated with the EHR.
Has administration tools for scanning and indexing non-electronic
documents.
Has ability to annotate, mark-up, and sign scanned documents (e.g.,
ophthalmology or dermatology)
Has OCR capabilities to allowing querying scanned documents and
EOBs.
Has integrated speech recognition capabilities with speech to text and
command and control (navigation) features.
Demonstrated ability to eliminate transcription using templating and
speech recognition.
User can review and sign notes for own visits and calls.
Multiple users can review and sign all documentation.
Ability to do dual routing (e.g., lab results go to a “team” for follow up).
Ability to hold records in different stages of completion.
User can print entire patient record.
User can electronically transmit patient record within the enterprise.
Has lists of providers’ most used charges per provider.
Ability to provide real-time billing updates and notification back into
Practice Management System without any manual intervention (e.g.,
changes to insurance, situational data elements, and special billing
functions).
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Vendor 1 1-5 Vendor 2 1-5 Vendor 3 1-5
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Functionality
Planned/ Planned/ Planned/
comments comments comments
Automated tasks to remind physicians of missing charges and
complete reconciliation features to the Practice Management System.
Has option to carry forward review of systems, problem list, medication,
etc. from last visit.
Has a standardized nomenclature that is integrated with clinical
CT
documentation (e.g., Snomed , Medcin).
Nomenclature is used to automatically calculate charge codes.
Ability to flexibly document conditions including expanding details
(severity, location, etc.) for each clinical finding.
Ability to add comment and detail to each clinical finding.
Physicians can use nomenclature to build their own templates without
programming or complex forms.
Automatically update nomenclature monthly to each facility.
Display clinical relevant terms based on current findings.
Ability to insert anatomical markups into documentation.
Has the ability to document visit using pre-built templates.
Has option to default review of systems information to “all normal.”
WORKFLOW
Has work lists/to do lists/tasks per user.
Ability to direct work/charts to others for completion on an “as needed”
basis.
Has the ability for managing triage calls with the ability to redirect to the
provider.
Has user-defined automatic routing of information (messages, lab
results, other tests, etc.) with override capabilities.
Has lists of providers’ most used problems per provider.
Has lists of providers’ most used medications per provider.
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Functionality
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Has ability to track Waiting Time in each station, for real time
awareness.
CLINICAL CONTENT
Patient education materials for new medications.
Integrated evidence based guidelines (PIER) for adult medicine.
Ability to capture CME credit for usage of the guidelines.
Supplies more than 500 health management plans that can be
customized per physician.
PMS Features
Appointment scheduling
Telephone Triage
Referral Management
Office Messaging and Workflow
Patient Demographics
Patient Insurance
Charge Capture (ICD & CPT)
Claims Management
Receivables Management
Patient Statements
Clearing House Capability
Financial Analysis Reports
Super Bill, Reports
Other Features
Document Generations: Letters creation with mail merge
Document Scanning
Digital Audio file interface
Ability to integrate with medical equipment such as ECG’s etc.
Technical
Interfaces Maintenance
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Health Center Score
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Vendor 1 1-5 Vendor 2 1-5 Vendor 3 1-5
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Functionality
Planned/ Planned/ Planned/
comments comments comments
Future Enhancements
Other Questions
Able to pull consultation reports from software for "Store and Forward"
Telemedicine and send to provider's "Inbox" for review and signature.
Ability to update Managed Care Plan Formularies (Medication)
Transfer information from Home monitoring devices to HER?
User friendly, simple to use, with ability to update with touch-screen
capability
Following to be recorded at the Demos
Diabetic - Established Patient (Male, Adult) presents to the receptionist for
scheduled appointment
Patient Rep
Verifies patient has appointment
Flows patient to “Waiting”
Pulls chart
Verifies demographic information is current
UPDATES all necessary forms
o Patient Registration Forms
o Learning Assessment Questionnaire (needed annually)
o Health & Lifestyle Assessment
o Staying Healthy Assessment
o Adult History Form
Verifies Financial Class is appropriate for Visit Type
Prints labels for Superbill
o See Superbill Form
Depending on Financial Health Coverage:
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Health Center Score
Health Center Score
Health Center Score
Vendor 1 1-5 Vendor 2 1-5 Vendor 3 1-5
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Functionality
Planned/ Planned/ Planned/
comments comments comments
o Scan/Make copy of Private Insurance Card & Insurance
Benefits Form
o Scan/Make copy of Medi-Cal or Managed Care Card &
Eligibility Forms
o Scan/Make copy of Medicare Insurance Card and
applicable form
o Scan/Make copy of Income Analysis Forms (for our
Sliding Fee Patients)
Collect Co-Payment as applicable and document into the
Practice Management System
Print Receipt (we are looking into Point of Sale Devices)
Document Post-it notes as applicable
Document financial notes as applicable to become part of the
Chart
Chart up in provider cubby
Light on for provider to notify patient is ready for the Back
Office
Patient Care Associate
Pulls chart from provider cubby
Prints “PECS” Encounter Sheet FORM (Page 1 & 2) from PECS
Registry
Documents into the PECS Encounter form Vitals, Medications,
etc (see form)
Inserts PECS encounter note or progress note in chart
Verifies all required information is available for provider to
complete visit (results, consultations)
Flows patient to the next Station “Exam Room” (to track
Waiting Time)
Calls patient back
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Functionality
Planned/ Planned/ Planned/
comments comments comments
Performs CLIA Waived Tests; UA, Blood Sugar, Hemoglobin A1C
(provider driven)
o Document into the CLIA WAIVED TEST Report
o Urine strip with results are attached to the form
Takes patient to exam room
Completes baseline Vital Signs
Additionally, documents drug allergies and medication list into
the Permanent Pt Database Form
Documents Chief Complaint or “Diabetic Routine Visit”
Patient removes shoes; PCA performs Diabetic Foot Screen as
necessary
o Use the FHCN Foot Screening Form
Pulls flag system to alert provider
Provider Visit
Reviews Permanent Patient Database Form
o Major Problem List
o Allergies
o Medications
o Learning Assessment
o Surgical History/Hospitalizations, Tests
o Age Specific Preventive Health Guidelines
Reviews Health Care Maintenance Form
Reviews existing Progress Notes and/or previous PECS
Encounter Forms in the medical chart
Enters exam room with patient
Performs consult/exam using
Orders Labs
o Into the Quest Lab Requisition Form
Orders Referrals (as applicable)
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Health Center Score
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Vendor 1 1-5 Vendor 2 1-5 Vendor 3 1-5
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Functionality
Planned/ Planned/ Planned/
comments comments comments
o External Referral to Specialty Care Form
o Internal Referral to Behavioral Health Form
o Internal Referral to Health Education Form
Prescribes Medications as necessary
o Rx written for external Pharmacy or
o RX given view FHCN Dispensary
a) Completes the Dispensary Form (as applicable)
b) PCA takes patient to Reception to pay for
medication
c) Patient Rep takes money and prints receipt
d) Patient is taken back to exam room
e) PCA takes receipt to Dispensary and acquires
medication
f) PCA takes medication to exam room for provider to
dispense
Provider will complete and sign Superbill
PCA will schedule follow up appointment if required
PCA will flow patient “Out” (To track Waiting Time of patient
with the Provider)
Patient leaves
Provider FOLLOW up
Consultation Reports comes back via mail
o Consultation Report is placed on the provider desk with
Chart
o Provider reviews and signs Consultation
o Consultation Note and Chart returned to Medical Records
for Filing
Lab Results come back via fax/printer
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Vendor 1 1-5 Vendor 2 1-5 Vendor 3 1-5
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Functionality
Planned/ Planned/ Planned/
comments comments comments
o Lab Results are placed on the provider desk with Chart
o Provider reviews and signs Lab Results
o Lab Results and Chart returned to Medical Records for
Filing
Communication with Medical Assistant
o If abnormal Lab Results, provider notifies Medical
Assistant to contact pt for follow up appt.
o Medical Assistant documents into the Chart that patient
was contacted
Refill
o Pt calls for a Refill
o Chart pulled for Dispensary
o Dispensary will authorize refill according to FHCN policy
o When refill request does not fall within policy, chart is
routed to provider for authorization
Cough and Cold, Visit (make this one as QUICK as you can)
Child (9 yr old) Patient presents to the receptionist for scheduled
appointment
Patient Rep
Verifies patient has appointment
Flows patient to “Waiting”
Pulls chart
Verifies demographic information is current
UPDATES all necessary forms
o Patient Registration Forms
o Learning Assessment Questionnaire (needed annually)
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Functionality
Planned/ Planned/ Planned/
comments comments comments
o Staying Healthy Assessment (Pre-Adolescent 9-11)
o Pediatric History Form
Verifies Financial Class is appropriate for Visit Type
Prints labels for Superbill
o See Superbill Form
Depending on Financial Health Coverage: (scan/make copy as
see above))
Collect Co-Payment as applicable and document into the
Practice Management System
Print Receipt (we are looking into Point of Sale Devices)
Document Post-it notes as applicable
Document financial notes as applicable to become part of the
Chart
Chart up in provider cubby
Light on for provider to notify patient is ready for the Back
Office
Patient Care Associate
Pulls chart from provider cubby
Places FHCN Preprinted Progress Note Form with pre-printed
Vital Signs
Documents the following
o Ht , Wt, Temp, Resp, Pulse, BP, PAIN, BMI
o Last Menstrual Period, Birth Control Method, Lactating
o Smoking (Exposed), Immunizations Up to Date (pretend IZ
are up to date)
o Review Vaccine Immunization Record
Flows patient to “Exam Room”
Calls patient back to exam room
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Functionality
Planned/ Planned/ Planned/
comments comments comments
Performs Baseline Vital Signs and
Documents drug allergies and medication list into the
Permanent Pt Database Form (Page 1 & 2)
Documents Chief Complaint into FHCN Preprinted Progress Note
Form
Verifies all consults, labs, transcription from last visit in medical
record
Pulls flag system to alert provider
Provider Visit
Reviews medical chart
Enters exam room with patient
Performs consult/exam
Prescribes Medications as necessary (see as above either RX
for Pharmacy or FHCN Dispensary)
Provider will complete and sign Superbill
PCA will schedule follow up appointment , e.g. schedule Well
Child Exam
PCA will flow patient “Out”
Patient leaves
Routine OB Visit for 2nd Trimester Visit
Female Patient presents to the receptionist for scheduled appointment
Patient Rep
Verifies patient has appointment
Flows patient to “Waiting”
Pulls chart
Verifies demographic information is current
UPDATES all necessary forms
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Vendor 1 1-5 Vendor 2 1-5 Vendor 3 1-5
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Functionality
Planned/ Planned/ Planned/
comments comments comments
o Patient Registration Forms
o Learning Assessment Questionnaire (needed annually)
Advance Directives was pending. Advanced Directives Form
given to pt.
o Pt Rep will document into the Permanent Pt Database
form that Advance Directive Information was given
Notice of Privacy Practice was pending. Notice of Privacy
Practice Form given to pt.
o Pt Rep will document into the Permanent Pt Database
form that Advance Directive Information was given
Verifies Financial Class is appropriate for Visit Type
Prints labels for Superbill
o See Superbill Form
Depending on Financial Health Coverage: (scan/make copy as
see above))
Collect Co-Payment as applicable and document into the
Practice Management System
Print Receipt (we are looking into Point of Sale Devices)
Document Post-it notes as applicable
Document financial notes as applicable to become part of the
Chart
Chart up in provider cubby
Light on for provider to notify patient is ready for the Back
Office
Patient Care Associate
Pulls chart from provider cubby
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Functionality
Planned/ Planned/ Planned/
comments comments comments
Places blank ACOG forms and “Antepartum” Progress Note in
chart if needed
Flows patient to “Exam Room”
Calls patient back to exam room
Performs CLIA Waived Tests; UA and documents results
Performs and Documents baseline Vital Signs
Verifies all pertinent information is in medical record; labs,
sonogram results
Pulls flag system to alert provider
Provider Visit
Reviews medical chart
Enters exam room with patient
Performs consult/exam
Documents on ACOG forms
Orders a Lab for AFP Screening
Hands off patient to Health Education/Case Manager for 2nd
Trimester Education
Provider/PCA team completes California Expanded AFP
Screening Program Form
Completes and signs Superbill
PCA will schedule follow up appointment
PCA will flow patient “to Health Education”
Health Education Visit
Reviews medical chart
Provides 2nd Trimester Specific Education & documents into
applicable ACOG Form
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Functionality
Planned/ Planned/ Planned/
comments comments comments
Provides education on AFP Screening and give pt the Booklet
“Choices in Prenatal Testing for Women 35 Years and Older”
Completes Perinatal Combined Assessment/ Reassessment
nd
Tool (10 pages) 2 Trimester Section
Provides handouts to patient, e.g. Smoking pamphlet and FHCN
Schedule of Prenatal Classes
Sign patient up for Prenatal Class 1
Patient leaves
Health Educator will remove pt our of Flow (to stop tracking
Waiting Time)
Health Educator will also sign off the Superbill
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