What do you write in a Referral tab? ** Answ** 1. Check off include summary of care
2. Reason for referral- follow up
What do you write for Advance Imaging tab? (7 things) ** Answ** 1. Priority
2. Type
3. Body Part
4. W/ contrast w/o contrast
5. Wet Read Required
6. Relevant PE
7. Eval for ?
What are examples of Advance Imaging? ** Answ** CT/MRI
What are in Orders? ** Answ** x rays
What do you bring the X ray Technician? ** Answ** The printed xray order with the exam
room # and x ray of what written on top of paper
What do you write in Xray tab? ** Answ** In note to imaging facility-- PE: Eval for
How do you put a X ray order in/find x ray? ** Answ** 1. In Assessment & Plan
2. Type xray body part
3. Click orders
Where/What do you put the X ray results? ** Answ** In PE under xray Wet Read
Type in results & .... providers initials
What is in Order Sets? ** Answ** STAT US, CBC, CMP, CT, MRI, Referrals, injectable
medications
How do you put in a referral/ find referral? ** Answ** 1. Assessment & Plan
2. List
3. Specialist (Cardiology, Urology)
What procedures go into procedure documentation? ** Answ** EKG, Abscess, Laceration,
Suture, Blood draw, Abdominal pain panel
, Where do you place lab vaccines? ** Answ** Reason for visit
When do you discharge a patient ** Answ** When they have a urgent order ER
When dont you discharge a patient? ** Answ** When they have a Stat order or List Referral
order
Who do you tell for a Stat Advance Imaging order? ** Answ** PCR/Manager
Who do you tell for a Stat Lab? ** Answ** MA/Manager
Who do you tell for a List Referral? ** Answ** PCR/Manager
What do you put in injectable meds tab? ** Answ** From
1. Site
2. Dose
3. Lot #
4. Expiration
5. Check off administered
Reviewing all the sections in the Past Medical History tabs is NOT mandatory for Established
Patients. True or False ** Answ** False
Which of the following is required to be addressed within every patient Referral order?
Reason for Referral
Patient's Insurance
Include summary of care record
Documentation only
Patient's Date of Birth
Urgency ** Answ** Reason for referral
Include summary of record
What are the correct areas that must be addressed for complete documentation of a Point-of-Care
test?
Results
Collector
Discussed with patient
Standing order
Note
Source ** Answ** Results
Discussed with patient