Electronic Health Records22

Report
PENDING RESULTS
CHAPTER 22
OBJECTIVES
• Process the incomplete charts using the Pending
processors
• Process a referral using the Referral dashboard
KEY CONCEPTS
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Results pending
Incomplete visits
Referrals and referral reminders
Surgery/procedure authorizations
Appointments need authorizations
Further review needed
Charts needing review
Employee health
Open cases
On-line open case aging
Rehab services appointments to schedule
Company log review
PENDING RESULTS
• When patient leaves facility medical treatment for
visit is complete but there could still be results
pending for tests, treatments not provided at facility
• Incomplete visits are defined as patient encounters
which results are pending for x-rays, lab tests,
treatments and opinions from referrals/specialists
• Important to track results of outside
testing/treatments
• Physician needs to review results of these in timely
fashion as the patient’s health care is important
PENDING RESULTS
• Patient’s health could be at risk is these results are
delayed
• Every step in patient’s treatment could be perfect
but misfiling test results or lack of notification to
physician that results are back could cancel all of
the positive effects of patient’s care
• MedTrak’s Pending module also provides
functionality to manage billing issues, track referrals,
manage authorizations and review company
demographic changes
PENDING MENU
• To access Pending Menu sign in to MedTrak click
Pending Menu tab at top of screen-Figure 22-1
• Pending Menu provides access to the following:
• Incomplete Visits-consultations, occupational
medicine, orthopedic visits
• Patient Responsibility
• Physicals-employee physical examinations, drug
screens
• Rehab Services-for physical/occupational therapy
• Referrals-reminders
PENDING MENU
Surgery/Procedure authorizations needed
Appointments
Further Review Needed
Charts Needing Review
Open Cases-tracks open workers 'compensation
On-Line Open Cases Aging-monitors open time of
workers 'compensation cases
• Held Cases-physician waiting on additional info before
clearing them
• RS Appts to Schedule-manages appointment
authorization for referrals to in-house rehab
• Company Log Review-reviews demographic changes to
employers information
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INCOMPLETE VISITS
• Typically within 1-2 days radiologist will finish reading
x-ray(overread) and communicate results to facility
• When results arrive administrative staff member
enters information in patient’s x-ray overread order
in MedTrak
• You can do this by accessing MedTrak Main Menu
and click Pending Menu
• Click Patient Responsibility button in Incomplete
Visits section on Pending Menu
• Next screen is Incomplete Patient Responsibility
screen-Figure 22-2
INCOMPLETE VISITS
• Initial view for this screen is alphabetical by patient’s
last name to find a patient you can reset the view
by date of service or by company is it is workers’
compensation
• All incomplete visits screens list patient names, their
employers(patient responsibility) flags representing
what is still incomplete for visit, date of service, type
of visit(I-initial, R-return) and MedTrak employee
initials of provider
INCOMPLETE VISITS
• Each Incomplete Visits screen uses FLAG to indicate
what is still pending for visit
• These flags represent incomplete steps in processing
patient’s visit
• Administrative staff member completes step
represented by one of flags the flag clears from line
and once all flags clear patient drops off processing
screen
• Incomplete Visit table lists incomplete visit flags and
what screens use them-Figure 22-3
FIGURE 22-3
INCOMPLETE VISITS
• To enter results of over-read by radiologist place
cursor in command field for patient and click X-ray
orders button
• Next screen is Radiology(x-ray) category of Visit
Orders screen-Figure 22-4
• This screen reflects information related to report
from radiologist
• Enter date report arrived back at facility
• Scan radiologist’s report including
narrative/summary and attach to patient’s case
FIGURE 22-4 & 22-5
INCOMPLETE VISITS
• In each Narrative and Summary fields enter
“sr”(trigger for See report)
• Enter employee initials for radiologist in Radiologist
answer field-Figure 22-6
• If you do not know radiologist’s initials use F1 key in
answer field to access help screen displaying all
available radiologist for facility
• After entering data click Submit Answers button
• X-RAY OVERREAD order details screen refreshes with
answers showing to right of questions-Figure 22-7
INCOMPLETE VISITS
• The remaining step in medical workflow is ordering
physician to review narrative and summary from
radiologist
• Click EXIT screen on X-RAY OVERREAD order details
screen and return to x-ray section of Visit Orders
screen-Figure 22-8
• X-RAY OVERREAD order is still incomplete because
ordering physician needs to review radiologist repot
• Click Exit screen on Visit Orders screen to return to
Incomplete Patient Responsibility screen to process
next results report that facility has received-Figure
22-9
INCOMPLETE VISITS
• Once physician reviews radiologist’s report the XR
flag will automatically clear and patient visit will
drop of incomplete processing screen
• Click Exit screen again to return to Pending Menu
• The medical workflow disciplines for over-read of xray called for administrative staff to prepare the xray to send to radiologist and then record results of
read
• Final step is ordering physician to review report
• Do This! Pg. 268
FURTHER REVIEW NEEDED
• MedTrak alerts ordering physician that over-read xray by radiologist is back and ready to review by
placing an entry in Physician’s Further Review
Needed processor
• Click Further Review button on Clinic Status screen
or click Further Review Needed button on Pending
Menu-Figure 22-10
• Screen displays MedTrak employee initials of staff of
facility who have action items that need further
review
FURTHER REVIEW NEEDED
These items could involve one of the following:
X-ray over-read results
Lab results
Referring treatment results
Questions concerning billing
Any other question about a case from another staff
member
• To review chart place cursor in Command field next to
physician’s MedTrak employee initials and click Submit
button
• Next screen to appear is Further Review Needed/Staff
screen-Figure 22-1
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FURTHER REVIEW NEEDED
• To review X-RAY OVERREAD order place cursor in
command field next to it and click Show Order button
• On X-RAY OVERREAD order details screen review
radiologists report by opening up scanned document
that administrative staff attached to patient case
• Enter MedTrak employee initials in Reviewed By answer
field-Figure 22-12
• Click Submit Answers button, X-RAYS OVERREAD order
details screen refreshes with physician’s name to right of
Reviewed By question
• After reviewing screen click Exit Screen button to return
to Further Review Needed details processor-Figure 22-13
• Click Exit Screen button again to return to Pending Menu
• Do This! Pg. 271
REFERRALS TO SPECIALISTS
• When physician refers a patient to specialist to have
scheduled test he/she places order for a referral
• In a referral order the physician documents these:
• Body parts needing examination or treatment
• Any special notes specialist should know about
patient
• How soon visit must happen
• Whether referral is for evaluation only or evaluation
and treatment or for specialist to take over patient
care
REFERRALS TO SPECIALISTS
• Once physician place referral order appears on
Referred Dashboard for scheduling/processing by
administrative staff
• Click Pending Menu tab on MedTrak main Menu
then Dashboard button in Referrals section of
Pending Menu-Figure 22-14
• Next screen is Figure 22-15-Referral Dashboard
• The totals on this screen represent total number of
referrals that are: pending, approved, denied,
scheduled, completed, and reviewed
• Do This! Pg. 273
REFERRALS TO SPECIALISTS
• To display individual referrals on Referral Dashboard click
on number which displays:
• Location
• Status
• View
• Search
• Date ordered
• Patient name
• Type of referral
• Referral status
• Select
REFERRALS TO SPECIALISTS
From this screen, use buttons to:
Select
Visit Log
Case
Visit
Notes
Reminders
Pending column displays Referrals screen for patientFigure 22-16 an asterisk next to number on Referral
Dashboard indicates referral needs immediate attention
• Place cursor in command field next to patient order and
click Select button-Figure 22-17 first detail screen displays
individual questions that need answering to process and
complete referral
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REFERRALS TO SPECIALISTS
• Referral order screen displays:
• Header-referral order name, date ordered, clinic
location, company name, patient name, reason for
visit
• Function field-allows access to many other functions
• Order details-physician questions
• Administrative staff(clerical) questions-Referral step
• Referral step
• Referral notes
• Reminder
• Consultation/Specialist
REFERRALS TO SPECIALISTS
Appointment Date
Appointment Time
Medical records
Scheduling Clerk
Consultant Report Return Date
Consultant Summary
Answering this question moved referral to
Completed column on Referral Dashboard
• Physician questions-reviewed by-answering this
question moves referral to consultant report using
Further review Needed processor
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REFERRALS TO SPECIALISTS
• Figures 22-19 and 22-20 and 22-21
• Do This! Pg. 278 & 279
AFTER THE REFERRAL VISIT
• After patient’s referral visit referral specialist will
report back to referring physician
• When report arrives back at facility and
administrative staff member enters information in
referral order for patient in MedTrak
• Figure 22-2
Referral Dashboard
• Figure 22-23
Referrals
• Figure 22-24
Orthopedic Consultation
• Figure 22-25
Orthopedic Consultation
• Figure 22-26
Referral Dashboard
• Do This! Pg. 282
FURTHER REVIEW NEEDED
• MedTrak alerts ordering physician that report from
orthopedic consultant is back and read y for
physician to review by placing an entry on
physicians Further Review Needed processor
• Figure 22-27
Further Review Needed
• Figure 22-28
Further Review Needed/Staff
• Figure 22-29
Orthopedic Consultation
• Figure 22-30
Further Review Needed/Staff
• Do This! Pg. 285
CLOSING THE REFERRAL
• Since physician has reviewed the consultant’s report
referral is now in Reviewed column on Referral
Dashboard
• Administrative staff can now close referral
• Access referral access Referral Dashboard off Pending
Menu Click on number in Reviewed column for facility
location –Figure 22-31
• On Referral screen listing from Reviewed column close
referral and clear it from Referral Dashboard enter “clos”
in command field-Figure 22-32
• Press Enter key Referrals screen refreshes with referral
cleared off screen-when done Exit screen and return to
Referral Dashboard to continue processing others
• Do This! Pg. 287
PRINTING THE PATIENT’S CHART
• You will need to print patient’s chart for incomplete
visit documentation to turn in for your assignment
• Do This! Pg. 288

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