In most clinics the MA's and RN's aren't creating chart notes themselves but can be there to help the provider either by supplying information about vitals and IV set up and gathering subjective information from the patient
To preserve the integrity of a providers chart OptiMantra has built out the Support Staff Clinical workflow to be accessible from the patient’s actions menu. Here are some steps for their clinical workflow.
TABLE OF CONTENTS
- Submitted Intakes
- Add Vitals
- Dashboard (Medical History Review)
- Labs
- eRX
- Custom Formulations
- Charting
Submitted Intakes
Patient Actions Menu > Submitted Intakes: Review all forms completed by the patient prior to the visit
- If any forms are missing they can use the Kiosk mode to have the patient complete their remaining paperwork or select actions menu > consent forms, actions menu > custom questionnaire, or actions menu > intake to complete the missing required documentation directly with the patient.
Add Vitals
Patient Actions Menu > Add Vitals gives the patient the ability for the clinical support staff to record the patients vital signs and begin the subjective note for the patient.
- Clinical Templates - SOAP and Categorized templates - can be used in the subjective section if specific intake questions need to be addressed, or for quick review of systems documentation.
Once the provider is documenting in the chart note they can navigate to the vitals section, and select “import vitals” and select that days date. It will then drop in the information documented by the clinical support staff.
Dashboard (Medical History Review)
Patient Actions Menu > Dashboard: At the top you will see the sticky note, patients clinical profile, and all meds/supplements. These 3 items can be reviewed and updated by the clinical support staff and are visible to the provider on the left hand side of the patient's chart note. *In addition, the clinical profile and all meds/supplements sections can be maintained by the patient on the patient portal.
- The provider can quickly pull this information into their chart note in the subjective section with the quick buttons for “copy clinical profile” and “copy all meds/supplements”
- The Dashboard is also a great spot to see an overall picture of that patient including any open tasks, their visit history, and a snapshot of their patient timeline
Labs
Patient Actions Menu > Lab / Diagnostics: This button gives the ability to create lab orders for the provider. From the 123 stacked bar icon they can also see the lab history.
eRX
Patient Actions Menu > eRX: If added as a staff member to eRX they can assist with maintaining the patient's information and pharmacies, set up scheduled prescriptions for the provider to sign and send new non-schedule prescriptions.
- To add a staff member please contact the OptiMantra customer support team via “create a ticket”
Custom Formulations
Patient Actions Menu > Custom Formulations: Staff has the ability to prepare the custom formulations (i.e. Iv’s or injections) for that day’s procedure. This gives them the ability to complete the template, pull in inventory, and prepare the chart note.
- When the provider is ready to document in the chart note they select the patient actions menu > formulations and can quickly add it to their plan and services
Charting
Please note a chart note should always be started and only documented on by the practitioner as whoever starts the note will be the name digitally attached to that note. However, if your clinical support staff has charting access and the provider has granted the ability for other users to edit the chart, the clinical support staff can assist with documentation within the chart note itself AFTER the provider starts the note. If you want your MA or any other helper to assist you to edit and finish your provider chart notes; you have to make them have practitioner status in the user set up and you must pick yes for "Others can edit my chart" button bottom left of the Edit Access Control box in the Provider's User status box. If your MA or RN are listed as practitioners to help you with charting; and you don't want them to have their own charts, instruct them to use the edit feature in your patient's Charting history
We highly recommend that if you are going to let MA's and RN's start chartnotes with their name on them; then the provider should set themselves up as co-signer in the user box for the MA or RN. The MA or RN can finish the note and then notify the provider by going to the drop down list upper right using the "Request a signature from the cosigner" and that creates a task notification for the cosigner.
If your clinical support staff will have charting access but will not be seeing patients on their own as a practitioner you will want to remove them from showing on the schedule. This can be done in settings > scheduling > provider calendar. Select the clinical support staff’s name from the drop down and then toggle practitioner shows on calendar to “Practitioner Does Not Show on Calendar”
Pricing
Clinical support staff is defined as any user with reduced clinical access privileges, and who does not see, chart on, or bill patients independently.
Full-time clinical support staff RN/MA: $25/mo
Part-time clinical support staff RN/MA: $18/mo