Efficiently Recording Consults: A Step-by-Step Guide for Practitioners
When it comes to recording consults, practitioners need a seamless and efficient process to ensure accurate documentation and minimize administrative tasks. In this post, we'll outline the common method used by practitioners to record consults, and provide tips on how to save time when creating a consultation.
Initiating a Consultation
To initiate a consultation, follow these simple steps:
- Identify the patient's record in the system by using the coffee cup icon, which will turn red when the patient has been marked as arrived in the appointment book.
- Open the patient's clinical record to begin their consultation.
- To start recording the consult, select the patient's name, then click the stethoscope icon or use the shortcut (Control + K on Windows or Command + K on Mac).
- Alternatively, click the "Add Consult" button at the top of the window or use the shortcut (Ctrl + Rln on Windows or Command + N on Mac).
Consultation Process
The consultation process involves documenting various aspects of the patient's visit. To complete the consultation, follow these steps:
- Complete the history, examination, treatment plan, and diagnosis sections of the patient's chart.
Saving Time When Creating a Consult
To speed up the consultation creation process, consider the following tips:
- Create a list of common problems to streamline the consultation creation process and reduce the time spent on each consultation. To add a new problem to the EMR, select the "Select a Problem" drop-down menu in the top left corner of the screen, click "Add to Menu", and then enter the new problem and click "Okay".
- Configure macros to pre-populate text. Macros are customizable and can be tailored to meet the specific needs of your practice or department. Type in uncommon string text to trigger the pre-populated text.
- Use shorthand expansion for consultation notes. To expand shorthand, hit space or use the dropdown [Music] arrows.
Finalizing the Consult
Once you've completed the consultation, follow these steps to finalize the notes:
- Click "Okay" to finalize the consult, which will save a consultation note into the patient's clinical file.
- You have until midnight on the night of entering the consult to finalize any notes. After this time, only amendments can be performed for order purposes.
By following these steps and tips, practitioners can efficiently record consults and streamline their workflow, freeing up more time to focus on patient care.