Part 1: Encounter capturing

-Proper and accurate encounter completion is needed.

-Accurate encounters help with revenue collection and workload  credit tracking among other things.

-Telephone contacts , although non-billable, are counted as workload and can affect the budget for your institution.

-’Telephone contact’ cannot be for administrative issues but  has to involve medical decision-making

-Telephone contact is  “a call between clinical professional staff and patient” to:

-Coordinate medical/clinical advice
-Initiate therapy or a new plan of care
-Discuss test results in detail
-Provide medication refills or adjust medications
-The note must contain a problem (i.e. history) and a solution ( e.g. treatment plan)

 If the call was administrative only then enter

-an addendum, -a historical note  -or an administrative note

-This includes call to family and even conversations with other professionals on the case.

 Steps for Proper Documentation

1-Create a new visit by selecting the ‘correct’ clinic location

2- For Telephone encounters, use a Telephone clinic location

3-This will ensure that No bill will be generated.

So how does the way I enter encounters affect the patient?

•Example: Physician  (Provider) contacts patient at home (reduces his Insulin)
Patient is ‘happy’
•Physician documents call
•Creates New/Visit but selects ‘Primary Care Clinic’
• (Should have picked Telephone Clinic)!!
•Visit is categorized as 1st party co-pay based on stop code
•Patient gets a co-pay bill :
Patient is ‘not happy’

3 thoughts on “Part 1: Encounter capturing

  1. Saki

    Well, if the doctor fails drinug an EMR implementation, then they won’t be able to show meaningful use. So, of course that means that doctors won’t fail drinug the EMR implementation, right? (end sarcastic font)Nice to see that the AMA has seen what we’ve known for quite a while. If the EMR stimulus encourages the implementation of unusable and difficult to implement EMR systems, then those experiences will set EMR adoption even farther back than it already is.

  2. Adan

    You do have a gutsy EHR and business model, and I applaud your innovation. Help me understand your thinking. Is it: We’re not CCHIT certified and don’t intend to become certified. We’re not CCHIT certified but would like to be HITECH certified if the certification criteria were more reasonable We’re not CCHIT certified but intend to be HITECH certified as some point in the future something else? what I’m getting at is understanding how you present to physicians groups the probability that they will get ANY $$ from the Feds when they purchase you EHR: The probability certainly isn’t 100% since you’re not CCHIT certified today. but is it 0%? or somewhere in between 100% and 0% depending on how the certification process gets defined?


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