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Overview
Overview
Seeing patients is the bulk of what you will be doing as a Medical Assistant. Having a lot of face to face with patients means you will play a large role on how patients view the office as a whole. You will be grabbing patients, completing the work up and getting vitals and HPI, as well as dropping protocols, orders, in addition to other things.
Agenda
Agenda
In this section we will cover Methods of Professionalism During Clinic, Rooming, Taking CC and HPI, Adding Vitals, MIPs, and Orders/Other Charting.
Professionalism During Clinic
Professionalism During Clinic
Whilst sitting in the PODs, you will want to be sure that you display a level of professionalism as patients walk through. Whether they are one of your patients or not you play a role in the overall experience the patient has.
Things to be aware of in order to maintain a level of professionalism:
Use of Profanity
Inappropriate Conversations
Noise Level
Hygiene/Tidiness of Self and Work Area
Body Language/Slouching
Cell Phone Use
By keeping these in check you will help promote a positive and friendly work environment.
Rooming
Rooming
When rooming a patient communication with the team is key. Alert the team if they are around, letting them know who you are grabbing so that they don't try and grab the same patient. Once you call the patients first name, when they walk up have them confirm their last name and date of birth. This will ensure you have the correct patient as well as making sure not to break HIPAA guidelines.
Once you confirm you have the right patient, you will take them to the exam room and room them in Modmed. Be sure to do this right away so that the team knows that patient is being worked on and that the room is full. This will also allow us to gauge how well we are keeping up with the schedule.
See video below on how to room in Modmed
Chief Complaint & HPI
Chief Complaint & HPI
After you've roomed the patient you'll want to review the clipboard with the patient and talk to the about why they are here. The clipboard includes things like allergies, medications, medical and social history, etc. As you document keep in mind certain things like what type of pain or problem they have, where it's located, how often do they experience this, what makes it better or worse, how severe on a scale of 1-10, whether they've had treatment in the past. You'll want to make sure that these questions are answered while speaking with the patient. This will help the dr have an understanding of what the status and problem is. You'll want to make sure that what they are talking about is specifically regarding what their appointment is for. If they mention issues with a body part we did not schedule them for, you will have to kindly tell the patient that we will need to see them back as we only treat what they were scheduled for. This is in part due to authorization constraints.
Vitals
Vitals
You will need to get the patients Height and Weight, as well as either Respiration or Temperature.
See Video Demonstration to the Left on Ipad
MIPs
MIPs
You will need to include any required MIPs. All of the MIPs aside from the Advanced Directive are completed via Protocols. Please note that once MIPS is completed, if it's a once a year requirement, put the information in the sticky note with the year so that others don't have to worry about completing it.
Orders & Other Charting
Orders & Other Charting
Most orders are completed through the order plans in Modmed. The only one that isn't are the injections. Those are completed via PDF manager. Orders can include the following plans:
PT rx - A Script for Physical Therapy
Prescription - A Script for Medications
Order MRI - MRI Orders
Order CT - CT Orders
Order DME - DME Order
Please note that whether we are giving the DME to the patient or not, this order must be completed.
Order plain X-ray/Interpretation - Xray Order
Order EMG/NCV - EMG Orders
Order Tests - Lab Orders
Please note that all orders and scripts need the correct Locations. If it's to be performed at our office the location or facility on the order MUST be our office/dept. All others need to say Outside. This allows auths and scheduling to know which ones need to be authed and scheduled here.
DME
DME
If we are dispensing a DME that day, then the order needs to be in the note. Once auth is received and we complete the required steps in MotionMD and give the patient the DME, the Brace plan will need to be completed in the visit so that it can be billed.
See video demonstration below
If the patient is picking up the DME at a later date, the order needs to be completed and authorized and then you will initiate the dispensing process in MotionMD. You will complete everything you can and then under the Actions button, choose request followup. You will then print out the patient agreement in MotionMD and put it with the DME and bring it to the DME cabinet at Front Desk (Please only put the DME's at Front Desk when it is within a week for pickup as there isn't a lot of designated space). They will then get the patient to sign and submit when the patient comes to pick it up.
Completing PT Scripts
Completing PT Scripts
Therapy Scripts can be tricky depending on the body part.
Here are a couple things to keep in mind:
When choosing a diagnosis (DX), we want to try and choose the most accurate DX and not just a symptom as our primary DX. For instance if the patient is having arthritic pain, we would use Osteoarthritis as the DX rather than pain. As pain is a symptom of the arthritis
When creating orders for post op we have to pay attention to whether it's acute or chronic as some DX's are different depending if acute or chronic for example:
Traumatic/Acute Rotator Cuff Tear - the DX is S46.011D or S46.012D
Degenerative/Chronic Rotator Cuff Tear (AKA Non Traumatic) - the DX is M75.111, M75.112, M75.121, M75.122 depending on partial or complete
When it comes to hands and other body parts, when choosing the body location for the diagnosis and plan, we need to pick the body part that is related to the diagnosis. For instance if they have a finger laceration, we need to choose the actual finger rather than the hand as the location. If we don't this will lead to an unspecified DX.
If you are having trouble getting a specified DX, when you do your search, click complete code search and choose the ICD database tab. This will allow you to see the options that are from the ICD-10 Book itself.
When doing Bilateral PT you can either do two orders together or one order on a left dx and one on a right dx. If you do them together you will complete one side first and then choose the add body location option to add the other side. DO NOT DO THE BODY PICKER OVERRIDE. This will not make it Bilateral.
Click the button below for PT Cheat Sheets. Additionally we understand that you are not coders but the doctor needs to be clear in the diagnosis.
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