Once I have put the Cumulative Patient Profile into the EMR, I mark the front of the chart with a red line. This week, we decided to stop pulling red-lined charts.
We had to figure out how to mark the fact that a patient is in the exam room, since there is no chart on the door. On my scheduler, there is a drop down list beside the patient's name, where you can note that the patient has checked in, is a no show, etc. We added two more items to the list: "room 1", and "room 2". When the patient checks in, the scheduler automatically says "in" once their card has been swiped. When the patient is put in one of my exam rooms, my staff puts "room 1" or "room 2" on the scheduler, and I can see it in my EMR. For now, I put a sticky note with "1" or "2" on the door, but I'm going to buy more professional looking numbers.
I've made templates for the Ottawa knee rule and the Ottawa ankle rule. I don't see why these evidence-based rules can't be incorporated directly into the record; having templates makes it easy. I'm going to make a template for the Wells DVT rule. I've also made a template for the "5 A's" approach to quit smoking (ask, advise, assess, assist, arrange), with a drop down list for the stage of change the patient is at. This is the approach recommended by our Clinical Tobacco Intervention program, and there is a new fee code for doing this. I try to do it anyways, but now I can document it easily as well; I put a note on the template to remind me to bill the new smoking cessation code.
Three pap smears with electronic requisitions came back today from my lab because the requisition was non standard. I sent an email to the lab's IT manager asking him to please send a memo saying that electronically printed reqs are OK. The data on the reqs is the same. I like doing electronic reqs better, because it shows that a pap was done right in the patient record, and I can also track the pap to make sure it comes back. I don't want to go back to paper reqs.