Electronic Health Records For Dummies

After visit communications

You need to chart your methods for handling any communications that occur after the patient has left your office. This is where you think about how you talk and work with your employees and colleagues to relay vital patient information.

Prescription refills

• How do patients request a prescription refill?

• Who handles the call?

• How is the physician involved in the process?

• Can a nurse complete the refill for certain medications or patients without notifying the physician?

• How is the event documented in the paper chart?

Telephone calls

• How many patient phone calls are received each day?

• Who handles phone messages and is there a triage process?

• How many of each kind of message are received each day (scheduling, emergency appointments, medical question, advice, billing issue, lab results)?

• How is the physician involved in the telephone call process?

• How do you manage after-hours calls?

• How is the event documented in the paper chart?

Lab and other study follow-up

• How do you receive results for lab, radiology, and other studies?

• Does the physician review all results? If so, does he or she have the paper chart pulled at the same time?

• Who communicates results and findings to the patient? How is that communication documented?

• Do you send letters, call the patient, or some combination of the two depending on the results?

Referrals (incoming and outgoing)

• What information is sent to the referred physician or practice? ...