Sample Office Visit Dictation by ooi20907

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									                                                                                                   EHR Practice Profile Questionnaire


Practice Name
Practice Type                                Multispecialty                                      Single Specialty
List Specialties

Clinician Information
Clinician Name                                 Specialty                                  UPIN #




Hours of Operation
  Monday              Tuesday            Wednesday                Thursday           Friday        Saturday         Sunday




Holidays (Office Hours)




Practice Statistics (by clinician)
Please provide as much information as possible in order to gain the most insight into the practice’s volume
of visits and calls.
Clinician        Current Caseload               Number of Visits         Number of Calls            Faxes Daily (pharmacy,
                 Patient Panel Size                                                                  lab, other clinicians)
                                                Daily         Yearly         Daily      Yearly




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Part 1 of 3:
Please provide copies of all standard instruments/forms utilized by the practice to collect demographics, clinical
information, and billing information including; super bills, encounter forms (i.e. insurance, HIPAA, patient history),
referral forms, orders (physician, nursing), lab order forms, lab report forms, immunization records, chronic
care/disease tracking forms, abnormal result forms, medication renewal requests, school/work notes, etc. In order to
assess patient communication, consultant communication please include templates of correspondence to patients
including; abnormal results, visit follow up, visit reminder notice, missed appointments, etc.


General Practice Information Questions


Office Layout: Diagram of the layout (floor plan) This information is necessary to plan the infrastructure,
wireless plan.
How many Consult offices:                            Exam rooms:                   Nursing Stations:


Clinic Type: Article 28
                   Federally Qualified Health Center
Clinicial FTE’s: During practice hours, what is the maximum # of providers on site at one time?




Confidentiality issues: Does the practice have any special confidentiality issues related to charting,
such as behavioral health, AIDS, Alcohol & Drug abuse? Are you aware that those charts have different access
& release of information regulations?




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Current PC Use: What percentage of staff is currently using a PC workstation with Windows
technology?




Approximately how many staff members need additional basic PC\Windows training? Please refer to the
staff assessment tool in the tool kit to assist with this.




Staffing: Is the practice planning any staffing changes in the near future, what is your workforce
retention rate?




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Renovation Plans: Are there any plans for construction, renovation, expansion or moving of the
practice? If so, please explain.




IT Project Planning: Are there any other IT projects planned? Has the practice purchased any
hardware, software recently? If so, please explain.




Information Technology Support: What forms of IT support do you currently have? Onsite?
Contracted? Please include name, address and phone number of IT contact if applicable.




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Remote Access: Will providers or other staff need to access the database from remote locations;
home, the hospital, other affiliated sites?     Yes    No Is there any remote access currently
supported in the practice?       Yes      No If you answered yes, please explain.




Exam Room Workstations: Is your practice planning to use workstations in the exam rooms? Would
you like to have the option? Evaluate exam room environment, what ergonomic changes need to be
implemented? What additional furniture or mounting devices will be needed?




Wireless Devices: Is the practice planning to implement a wireless network, use tablet PC’s, laptops or
PDA’s?




Scanning Technology: Does the clinic currently use scanning software to store any patient
information?
               Yes                                  No                 Already in place




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Do you plan to implement a phone tree? (An electronic confirmation program)
               Yes                                  No                  Already in place


Implementation Questions

Start And Go-Live Dates: How soon do you anticipate purchasing a system? Do you have a
preference when you would like to begin the implementation? Do you have a go-live date in mind? Are
you comfortable with the Framework of the DOQ-IT project? Would you prefer to implement
incrementally? Please refer to the EHR roadmap. Create an anticipated timeline.




EHR Goals:
1) What goals do you expect to achieve with an EHR? What benefits do you hope to realize? There are
several technology options including e prescribing, e-labs, registries, etc.




2) Has your DOQ-IT representative identified the CMS Reporting Measurements?




3) Do you plan to submit the required data to CMS at the end of the project?




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4) Please refer to the CMS Physician Focus Quality Initiative: Chronic Disease and Prevention
Measures.




5) Do you have an IT Budget?




6) Has the practice engaged a health information technology consultant (in addition to QIO staff)?
                                                         Yes        No

         a) If “No” does the practice plan to hire a consultant:               Yes             No



STAFF PROFILE
Include all staff members. This information will be used, in part, to plan for system training.


Staff Name and Title                      Full / Part time        Job Function                      Chart Access?
Sample:
Anthony Shih, MD                          FT 5 days               Internal Medicine provider        Yes-daily
Claire Montgomery                         FT 5 days               Medical Assistant                 Yes-daily




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Part 2 of 3:
WORKFLOW OVERVIEW
Workflow Details:
Patient Registration: including other systems that also record patient information




Appointment Scheduling: including who makes the appointments, # of same-day appts., # of new patients per
day or month, # of walk-ins (Refer to the practice workflow tool)




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WORKFLOW OVERVIEW
Workflow Details:
Telephone triage and clinical phone calls: including how prescription renewals are handled. Describe each
type of prescription renewal in detail i.e., triplicate for controlled substances, chronic condition meds, etc.




Other Phone Calls: including how messages are communicated to the provider and staff members




Medical Records: including when and by whom charts are pulled, i.e. day before appt, morning of appt, who files
information in the chart, what is filed in the chart, is there a flow sheet?




Billing: including onsite billing vs billing service, provide a sample of current superbill




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Other Phone Calls: including how messages are communicated to the provider and staff members




Pre-visit tasks: including preparation of superbill, chart preparation, pre-visit appointment confirmation




Patient Check-in: including registration verification, co-pay collection, how “arrived” status is communicated to
clinical staff




MA/Nursing Tasks related to patient visits: including taking vitals, nursing orders, nurse-only visits




Provider Tasks related to patient visits: including chart review, order entry and follow up, visit documentation




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Dictation & Transcription: including how often dictation is done; method of dictation (digital vs tapes), how are
transcribed notes sent back to the practice, is any transcription done onsite?




Laboratory work: including where is blood drawn, use of onsite vs outside lab, % of tests per lab, how
are results reports received, electronic, courier, fax




In-house procedures, such as ECG’s: including how orders for tests are communicated, do you have an order
panel for specific chronic disease patients (see chronic care measures)? How are results documented? What is
the procedure for follow up and patient notification




Referrals & Outside Tests, including how are referrals ordered, authorized, scheduled and tracked. Is there a
referral coordinator? How many referrals do you have per week?




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Patient Check-out process: including what happens to completed super bill




Patient Correspondence, including missed appointment letters, HIPAA (NPP), follow up letters, medical record
requests, reminders, etc.




Part 3 of 3:

CHART REVIEW
You and your IPRO DOQ-IT team will review several charts from each provider and summarize how the
charts are organized. We will evaluate the different methods of documenting problems and treatment plans.
We will look at the following areas:
•   If your practice uses one, is there an up-to-date face/flow sheet with current problems, medications and
    allergies?


•   Are notes typically hand-written, transcribed, or completed forms?


•   What is the volume of outside consultant reports filed in the chart? What is the volume of visit notes that
    are sent out with consultant reports or letters?


•   Do all clinicians use the same method to record notes?


•   How are phone notes recorded in the chart?



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•   In order to ascertain which documents should be scanned into the chart, please define which documents
    you refer to most during the patient visit; i.e. problem list, medication list, allergy list.


•   Are there any “in-house” procedures performed that are documented on forms e.g. pulmonary function
    testing, Oxygen saturation, etc.?


•   Does the practice use drawings or graphics as part of the chart documentation, e.g., notations on a
    drawing of a body part to indicate position or size?
Other
•   Does your practice serve populations that speak other languages? Do you have the need for patient
    information in different languages?
•   How do you handle requests for Medical Records? Do you charge patients for Medical Record
    requests?
•   Are there any special billing requirements such as Article 28 Medicaid billing?
•   What is the practice’s average collections ratio:             % Unknown




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