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SBGR MedTrak

SBGR ALH 150 MEDTRAK Wk 2 (2012 EK)

Adding a new patient process of adding a new patient who is not previously established to the office’s database.
Blended checklists a list of conditions for medical staff to choose from when filling out patient information for a patient’s visit
Disciplines of medicine different types of healthcare
Payer responsibility relationship what type of insurance the patient has and what it will cover
Presenting problem(s) chief complaint of the patient
Problem-focused system appointments are scheduled according to the problem the patient is being seen for
Scheduled patients patients who have called the office prior to arrival to arrange a time to see the physician
Walk-in patients patients that do not have a scheduled appointment
Ages with reasons displays the patient’s age and the chief complaint for that day
Division the department that the facility is considered to be part of
Location the medical facility
Patient order status color-coded system that shows which patients have additional orders for treatment
Real-time workflow display that gives up-to-the-minute information on all patients being seen in the office
Workflow status information for registered patients, both scheduled and walk-ins, for that day
Data entry field area set aside for information and commands to be entered into the system using the keyboard
Expanded answer free-text answers with more space for wording
Medical history personal history that includes diseases, past injuries, etc.
Normal answers answers typically used and preset into the system that may be yes, no, normal, none.
On-line chart chart on the computer showing the questions and answers for the treatment notes
Presenting problem reason for visit, chief complaint
Rack indicates that the patient is ready to be seen by the physician
Reason for visit chief complaint
Standard answers short answer established by the computer program
Vital signs temperature, pulse, respiration, blood pressure
CPOE computerized physician order entry
Face time the time a physician spends with the patient
Open orders orders that are have not been completed
Physician access physician’s access MedTrak in many different ways to enter information for a patient
Problem-focused focuses mainly on the problem bringing the patient into the office
Touch-screen a device without a keyboard or many buttons that is activated by touching the screen
Voice recognition computer feature that will change a person’s voice into typed words or data
Workflow status clinic status of the patients seen in the office
Additional question types includes questions to be answered with someone’s initials and procedural questions
Age and gender specific certain optional questions can be age or gender specific
Cascade of questions pass the responsibility for the workflow steps from one discipline to another
Completed orders orders that have been filled or finished
Discipline columns indicates discipline is responsible for performing the next step of the open order
Evidence-based medicine medical methods that have been shown to be beneficial
Field indicators appear on the left of the input fields and include extra information.
Overread requested by the physician for a radiologist to read an X-ray
Procedural questions require the selection of options on another screen.
Procedure selection options options to choose from describing what treatment was given to the patient.
Quality control questions indicated by a red asterisk and must be answered before the patient can be discharged from the medical facility
Waiting times how long a patient has to wait be seen in the physicians’ office
Wet read the initial read of an X-ray by a physician
Workflow steps steps taken from the beginning of a patient’s visit to the end.
Assessment diagnosis made by the physician
Blink speed quick screen changes
Objective information obtained by a clinician such as vital signs
Out the door phrase used in the MedTrak system for showing the patient has been discharged
Plan course of treatment suggested by the physician
SOAP notes form of charting that follows subjective, objective, assessment, and plan format
Subjective the chief complain in the patient’s words or statement
Targeted information only information needed has been requested or queried
Visit documentation information recorded that summarizes a patient’s visit
Created by: SBGrandRapids