In this Quick Reference Guide, users will learn how to properly document Ear Irrigation during a Nurse Visit.
This Guide assumes that the user has a basic understanding of how to access the Intake MG template.
Nurse Visit Type
After launching the Intake MG template:
- Select Nurse Visit from the Visit Types pop-up menu.
- Click OK.
Historian
The Historian is the individual/(s) who provide information to the Nurse during Intake. To record this information:
- Click the Historian field.
- Select Self from the pop-up menu.
Use the Addt'l Historian/(s) field to record additional historians and their relationship to the patient. Information can also be free texted into the Historian fields.
Reason for Visit
In the Reason for Visit panel:
- Free text Nurse Visit (right/left) ear irrigation in the Other field.
- Click Add.
HPI
In the Generic Free form template:
- Free text pertinent information in the HPI section of the template.
- Click Save & Close.
My Phrases can be created and used to help expedite repetitive HPI documentation. (See How to Create My Phrases training material for details.)
Vital Signs
From the Vital Signs panel; click Add
In the Vital Signs template:
- Record patient Vital Sign information.
- Click Save
- Click Close
Adding Diagnosis Code
For billing purposes; a diagnosis is required to order Office Services. To add Diagnosis Code/(s) for today's visit; select Assessment from the Intake navigation bar.
Click the Diagnosis Code Lookup button from the Assessment template.
Diagnosis can be selected from the patients Assessment History and Problem grids if previously used. (See image below)
Searching for Diagnosis
In the Diagnosis Code Lookup window:
- Free text description of Diagnosis in Search field.
- Select Diagnosis from result lists.
- Click Select.
Ensure that the All Diagnoses option is selected before searching for diagnosis. (See Image Below)
Diagnosis Status
From the Diagnosis Status pop-up:
- Select the Active option.
- Click OK.
Ordering Ear Irrigation
To order the Ear Irrigation procedure:
- Select the Office Procedures tab.
- Select the Diagnosis from the Today's Assessments list.
- Click the Ear Irrigation point of care tests option.
- Click Place Order.
Completing Order
To complete the order, double-click the order.
In the Office Procedure orders template:
- Click the Completed check box.
- Free text the following: Irrigated (right/left) ear with warm water and peroxide flush. Impacted cerumen was removed. No complications noted. Patient tolerated the procedure well.
- Click Update.
- Click Submit to Superbill.
- Click Save and then Close.
Clicking the Completed check box will auto-populate the Performed check box.
Documenting Patient Instructions
To document patient instructions:
- Go to the A/P Details tab.
- Select diagnosis from the Today's Assessments list.
- Free text Patient Details.
Documenting Follow-up Information
From the A/P Details tab:
- Click Follow Up.
- Select Diagnosis from the follow-up order grid.
- Click follow-up check box.
- Click the Trimeframe field to select the desired follow-up timeframe option.
- Click Place Order.
- Click OK.
- Click Save & Close.
Generating Patient Plan
The Patient Plan should be generated for all Nurse Visits. To generate the Patient Plan:
- Go to the SOAP MG template.
- Select the Patient Plan icon at the bottom of the template.
The panels are collapsed in the illustration below.
Finalizing the Visit
To complete your documentation for the Ear Irrigation Nurse Visit:
- Go to the Finalize MG template.
- Select the 99211 visit code.
- Click Submit Code.
- Click Preview to generate Nurse Visit document.
