Electronic Health Records For Dummies

Intake/rooming the patient

After the front office indicates the patient has arrived and checked in, a medical assistant or nurse often initiates the intake process, rooms the patient, and updates the patient’s location status in the EHR.

Because an EHR changes practice workflows, you have an opportunity to optimize them. You can now delegate work that doesn’t require a physician’s license. Your practice can have individuals operate at the highest level of scope of practice for their position.

In addition to measuring and documenting height, weight, and vitals, the nurse can also review and document the patient’s medical history, document the reason for the visit, and perform an initial reconciliation of medications. Based on the reason for the visit or the problem/diagnosis list, the nurse likely has an opportunity to assist in preparing the patient for the physician. For example, if the diagnosis list indicates the patient has diabetes, the nurse may instruct the patient to remove his or her shoes and socks in anticipation of a diabetic foot exam.