Chart Prep is used to help simplify and speed up the process to assist with better efficiency and flow within clinic. This can be from as simple as creating the visit, to prepping Chief Complaint (CC) and History of Present Illness (HPI), or even as far as dropping protocols (templated portions of a note). By doing this we are able to effectively run clinic smoother and focus more on the patient rather than charting.
In this section you will learn the ins and outs when it comes to chart prepping and how to do it more efficiently
When creating the visit, you will generally go in through Appointment Flow. Under the filters option, you will select the providers and date that you are prepping for. Additionally, you will select "Confirmed" and "Pending". Once filtered you will be able to see a list of people that are on the schedule. On the right hand side you will then click on the button "Create Visit".
See the Video below for a visual guide
Previous Findings are used to pull over data from previous visits. CC/HPI, Exams, and Impressions (Diagnosis) and Plans. When pulling previous data, be sure to NEVER pull x-ray orders. This will cause an order to be added to the visit that can't be used causing problems with the x-ray staff and it also can't be deleted as the order shows already sent. When using previous findings, be sure to only include what you need and be sure it is a note from your provider as well as verify the date you are pulling from.
See to the right a video demonstration
When chart prepping for CC & HPI, some drs have templated information they want added. For instance some Dr's want any Medications, Surgeries, Injection, Therapy (PT), and other forms of treatment. Text Blaze is great for these templated HPI's as they can be added into the Text Blaze dashboard which will allow you to use this as a text shortcut. Click below for details on Text Blaze.
For CC, you'll want to pull up the appointment reason and see what problem they are having and what body part is affected and then add the chief complain "BODY PART" evaluation. For instance if they are having right knee pain, you will add a chief complaint "Right Knee Evaluation".
After completing that you can either choose applicable options, or you will select something and then save so that you can then override the HPI.
See the video below for a demonstration
Depending on the Dr. and what you are chart prepping for, you may need to drop in a protocol. For instance, if the appointment is for injection only, meaning the patient was seen already and they are just coming back for their injection after it was authorized, the Dr. will probably have an injection protocol. This will be a procedure note and will allow the injection to bill. It will also include the general medication preference as well as preferences on anesthetic and fluoro. This basically completes the note so that the Dr. can just do the injection and sign off on the note unless they need to adjust or change something based on patient specific findings, or other changes, but otherwise the note will be complete during chart prep.
Protocols can also be used for exams. Some Dr's may have exam protocols which will include their baseline testing, so that all they will have to dictate is their pertinent findings.
Protocols also get used for Postop visits. Generally post op patient are pretty routine in their healing so the note can be a top to bottom note with most of the information already there. The Dr. just has to review and fine tune if needed.
X-ray protocols are also available so that the Drs preferences on which views to select are already done.
See below for video demonstration
Injection orders are completed through the PDF Manager in Modmed. There are blank orders and there are templated orders. During Chart Prep, possible injections will be sent up to be preapproved in case the Dr. wants to perform an injection. If there are templated orders in the PDF manager under that drs name, then those would be the injection preferences. All you would need to do is select it, date it, and send as a task to auths.
For Possible DME's you would also submit them using the injection order form.
See video demonstration to the Right.
When patients are coming in for postop, if the Global Period identifier is not showing (the Goldish Yellow "GP" next to the patients name), you will need to add it for the visit. When a patient has a major surgery (Joint Replacements, Scopes, Most Fractures, etc) they are placed in a 90 day global period. Meaning all office visit codes related to the surgery are no charge for 90 days after the surgery. There are a select few surgeries that are considered minor (Kyphoplasty, a small number of fractures, and Incision and Drainage also called I&D). These have a 10 day global. These are generally based on type and complexity of surgery determined by billing standard. For the most part, the surgeries we perform other that those few mentioned are going to fall into the 90 day global. When you have a postop patient you will need to search for the "Set Global Period" plan. You will enter the SX date and then in other procedures performed, you will add the sx type and in the same section, add the physician name. For example: Left TKA - Dr. Fran. By adding the set global period plan, it will stop an office visit code from generating (99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215).
See Video Demonstration Below