|
The operation of the Consults package involves multiple people, at various skill levels, in various parts of the hospital. A consult request may be entered by a clinician or a clerk under a clinician’s direction. This request acts as a depository of information about itself.
It collects notes and keeps records on everything that happens to it. When complete it becomes part of the patient’s medical record.
In the pages that follow, we present this flow of information, and show the actions that must be taken at each step in the process. Many of these actions must be taken by persons other than those originating the consult.
Also, Consults uses CPRS during the initiation process and TIU during the completion process. In this section, we give some information about each of these packages that may help you in using Consults.
W orkflow
1. The clinician orders a consult. While in a patient's CPRS medical record, a clinician enters an order for a consultation or procedure.
2. The consult service gets a written copy. An alert and a hard-copy of the SF 513 are sent to the consult service.
3. If accepted, an appointment is held. To accept the consult, the service uses the receive action. The service can also discontinue or cancel the consult. Cancelled consults can be edited and re-submitted by the ordering clinician.
4. Results are entered and signed. The consult service enters results and comments. Resulting is primarily done using TIU.
5. The originating clinician receives an alert that the consult is complete. The results can now be examined and further action taken on behalf of the patient.
6. The SF 513 report becomes part of the patient’s medical record. A hard copy can be filed and the electronic copy is on line for paperless access.
1. The Clinician Orders a Consult
Consult orders can be entered:
From the CPRS medical record screen, Consults tab
CPRS GUI interface program, Consults tab
Ordering Within the CPRS Package
Primarily, Consult orders should be placed through the CPRS Add New Orders action.
In this manual we provide a step-by-step display of the process for ordering consult or procedures requests through the CPRS package. We first go through a brief list of steps, then we discuss each step in detail.
To Order a Consult:
A. Select CPRS Clinician Menu (OE) from the Clinician Menu.
B. Select the patient.
C. Select Chart Contents then Consults.
D. Select Order New Consult.
E. Answer questions on the particulars of the request.
To go over in detail how to order a consult:
Exactly how you do this option depends on how IRM or your ADPAC set up your menu. This example shows one way of performing step A.
Select Clinician Menu Option: ?
OE CPRS Clinician Menu
RR Results Reporting Menu
AD Add New Orders
RO Act On Existing Orders
PP Personal Preferences ...
Enter ?? for more options, ??? for brief descriptions, ?OPTION for help text.
Select Clinician Menu Option: OE
The screen now looks like this:
Patient Selection Apr 07, 1999 14:51:30 Page: 1 of 1
Current patient: ** No patient selected **
Patient Name ID DOB Room-Bed
No patients found.
Enter the number of the patient chart to be opened >>>
+ Next Screen CV Change View ... FD Find Patient
- Previous Screen SV (Save as Default List)Q Close
Select Patient: Change View //
Select the patient as you would in any other package. Type a patient ID such as the patient's name, social security number, or the patient's last initial followed by the last 4 digits of the social security number. If more than one patient matches the key you entered, select the patient from the list presented on the screen.
Select Patient: Change View // C2342
1 C2342 CPRSPATIENT,TWO 03-04-32 666902342 MILITARY RETIREE
2 C2342 CPRSPATIENT,TWELVE 02-03-23 666242342 MILITARY RETIREE
CHOOSE 1-2: 2 CPRSPATIENT,TWELVE 02-03-23 666242342 MILITARY RETIREE
Searching for the patient's chart ...
(Continued on the next page.)
The screen now looks something like this:
Cover Sheet Feb 13, 1999 12:53:14 Page: 1 of 2
CPRSPATIENT,TWELVE 666-24-2342 1A/B-1 FEB 3,1923 (74)
PrimCare: CPRSProvider, Three PCTeam: GOLD
Item Entered
Allergies/Adverse Reactions |
1 BEESWAX (hives, itching,watering eyes, | 03/28/97
anxiety) |
|
Patient Postings |
2 CRISIS NOTE | 02/25/97 12:18
|
Recent Vitals |
No data available |
|
Immunizations |
No immunizations found. |
|
Eligibility |
Not Service Connected |
+ Enter the numbers of the items you wish to act on. >>>
NW Enter New Allergy/ADR CV (Change View ...) SP Select New Patient
AD Add New Orders CC Chart Contents ... Q Close Patient Chart
Select: Next Screen//
C. Select Chart Contents then Consults
To get to the menu containing Order New Consults, you must go through the Chart Contents menu, then select the Consults screen. This can be done in one step by typing:
CC;CON
All Consults Feb 13, 1998 12:56:32 Page: 1 of 1
CPRSPATIENT,TWELVE 666-24-2342 1A/B-1 FEB 3,1923 (74)
PrimCare: CPRSProvider, Three PCTeam: GOLD
Consult/Procedure Requested Status
1 CARDIOLOGY Consult | 02/25/97 11:02 complete
Enter the numbers of the items you wish to act on. >>>
NW Enter New Allergy/ADR CV (Change View ...) SP Select New Patient
AD Add New Orders CC Chart Contents ... Q Close Patient Chart
Select: Chart Contents//
D. Select Order New Consult
Type NW and press the key.
Answer Questions on the Particulars of the Request
Select: Chart Contents// NW Order New Consult
Consult Procedure
Order new: C Consult
Delay release of these orders? NO//
Consult to Service/Specialty: POD FOOT CLINIC FOOT CLINIC
Reason for Request:
1>PERSISTENT SMALL FISSURES AND SCALING ON BOTH FEET.
2>
EDIT Option:
Category: INPATIENT//
Urgency: ROUTINE// ??
Select from:
1 STAT
2 ROUTINE
3 WITHIN 48 HOURS
4 WITHIN 72 HOURS
5 EMERGENCY
Select the urgency indicating how quickly results from this consult are needed.
Urgency: ROUTINE//
Clinically indicated date:TODAY//
P lace of Consultation: Bedside// ?
Select from:
1 Bedside
2 Consultant's Choice
Select the preferred place to see the patient for this consult.
Place of Consultation: Bedside//
Attention: CPRSPROVIDER,THREE CT PHYSICIAN
Provisional Diagnosis: TINEA PEDIS
-------------------------------------------------------------------------------
Consult to Service/Specialty: Podiatry
Reason for Request: PERSISTENT SMALL FISSURES AND SCALING ON ...
Category: INPATIENT
Urgency: ROUTINE
Place of Consultation: Bedside
Attention: CPRSPROVIDER,THREE
Provisional Diagnosis: TINEA PEDIS
-------------------------------------------------------------------------------
(P)lace, (E)dit, or (C)ancel this order? PLACE//
... order placed.
Add another Consult order? NO//
(Continued on the next page.)
The screen now looks something like this:
All Consults Feb 13, 1998 12:58:32 Page: 1 of 1
CPRSPATIENT,TWELVE 666-24-2342 1A/B-1 FEB 3,1923 (74)
PrimCare: CPRSProvider, Three PCTeam: GOLD
Consult/Procedure Requested Status
1 CARDIOLOGY Consult | 02/25/97 11:02 complete
Enter the numbers of the items you wish to act on. >>>
NW Enter New Allergy/ADR CV (Change View ...) SP Select New Patient
AD Add New Orders CC Chart Contents ... Q Close Patient Chart
Select: Chart Contents//
Notice that the consult just entered is not yet displayed. It is not displayed until after you have signed the order.
S ign the Consult
+ Next Screen $ Sign All Orders
- Previous Screen Q Close
Select: Sign All Orders// $ Sign All Orders
Enter your Current Signature Code: SIGNATURE VERIFIED
Processing orders ...
When applied to an approved medical record, an electronic signature has the same legal weight as a signature made with a pen on paper. For this reason electronic signatures are part of the overall security system maintained by IRMS.
When the computer prints a document that has been signed and/or cosigned, an electronic signature block is included. What appears in this block is user configurable through the User’s Toolbox option.
In this example we change a title and electronic signature:
Select Consult Service Tracking Option: ??
CS Consult Service Tracking [GMRC SERVICE TRACKING]
PC Service Consults Pending Resolution [GMRC RPT PENDING CONSULTS]
ST Completion Time Statistics [GMRC COMPLETION STATISTICS]
Or a Common Option:
CWA Patient Warning (CWAD) Display [GMRPNCW]
MA MailMan Menu ... [XMUSER]
TBOX User's Toolbox ... [XUSERTOOLS]
VA View Alerts [XQALERT]
Continue [XUCONTINUE]
**> Reverse lock ZZLUKE
Halt [XUHALT]
Restart Session [XURELOG]
Time [XUTIME]
Where am I? [XUSERWHERE]
You have PENDING ALERTS
Enter "VA VIEW ALERTS to review alerts
Select Consult Service Tracking Option: TBOX User's Toolbox
Select User's Toolbox Option: ?
Display User Characteristics
Edit User Characteristics
Electronic Signature code Edit
Menu Templates ...
Spooler Menu ...
Switch UCI
TaskMan User
User Help
Enter ?? for more options, ??? for brief descriptions, ?OPTION for help text.
Select User's Toolbox Option: ELectronic Signature code Edit
This option is designed to permit you to enter or change your Initials,
Signature Block Information, Office Phone number, and Voice and
Digital Pagers numbers.
In addition, you are permitted to enter a new Electronic Signature Code
or to change an existing code.
INITIAL: CRS//
S IGNATURE BLOCK PRINTED NAME: CPRSPROVIDER,SEVEN//
SIGNATURE BLOCK TITLE: DOCTOR// MD
OFFICE PHONE: 588-5029
ANALOG PAGER: 4038
DIGITAL PAGER:
Enter your Current Signature Code: SIGNATURE VERIFIED
Your typing will not show.
ENTER NEW SIGNATURE CODE:
RE-ENTER SIGNATURE CODE FOR VERIFICATION:
DONE
Select User's Toolbox Option:
The signature block, as changed in the example above, looks like this:
/es/CPRSPROVIDER,SEVEN
MD
The /es/ annotation indicates that the medical document was electronically signed
If for some reason you do not sign an order at the time you write it, then the system enters the order into your list of alerts. Signing the order is then simply a matter of responding to the alert as in the following example:
You have PENDING ALERTS
Enter "VA VIEW ALERTS to review alerts
Select OE/RR Manager Menu Option: VA View Alerts
1. CPRSPATIE (C0999): Order requires electronic signature.
2. TIUPATIEN (T3456): New Consult/Request (Stat)
Select from 1 to 2
or enter ?, A I, F, P, M, R, or ^ to exit: 1
Searching for the patient's chart ...
Unsigned Orders Feb 13, 1999 13:01:58 Page: 1 of 1
CPRSPATIENT,TWELVE 666-24-3456 1A/B-1 FEB 3,1923 (74)
PrimCare: CPRSProvider, Three PCTeam: GOLD
Item Ordered Requestor Start Stop Sts
1 CT ABDOMEN W&W/O CONT *UNSIGNED* | CPRSPROVIDER,THREE unr
2 Discontinue CBC BLOOD WC LB# 269 | CPRSPROVIDER,TEN unr
*UNSIGNED* |
3 Change SODIUM SERUM SERUM WC to GLUCOSE | pend
SERUM SERUM SP LB# 242 *UNSIGNED* |
4 Change GLUCOSE SERUM SERUM SP to | pend
POTASSIUM SERUM SERUM SP LB# 242 |
*UNSIGNED* |
Enter the numbers of the items you wish to act on. >>>
+ Next Screen - Previous Screen Q Quit
Select:Quit// 1
Unsigned Orders Feb 13, 1998 13:02:58 Page: 1 of 1
CPRSPATIENT,TWELVE 666-24-2342 1A/B-1 FEB 3,1923 (74)
PrimCare: CPRSProvider, Three PCTeam: GOLD
Item Ordered Requestor Start Stop Sts
1 CT ABDOMEN W&W/O CONT *UNSIGNED* | CPRSPROVIDER,THREE unr
2 Discontinue CBC BLOOD WC LB# 269 | CPRSPROVIDER,TEN unr
*UNSIGNED* |
3 Change SODIUM SERUM SERUM WC to GLUCOSE | pend
SERUM SERUM SP LB# 242 *UNSIGNED* |
4 Change GLUCOSE SERUM SERUM SP to | pend
POTASSIUM SERUM SERUM SP LB# 242 |
*UNSIGNED* |
Enter the numbers of the items you wish to act on. >>>
Change Sign
Discontinue Detailed Display
Select action: S Sign
-- CT ABDOMEN W&W/O CONT --
Enter your Current Signature Code: SIGNATURE VERIFIED
CT ABDOMEN W&W/O CONT signed.
Print CHART COPY for the orders: YES// YES
DEVICE: LTA35// C-ITOH 300 LINE PRINTER
DO YOU WANT YOUR OUTPUT QUEUED? NO// (NO)
Unsigned Orders Feb 13, 1998 13:03:58 Page: 1 of 1
CPRSPATIENT,TWELVE 666-24-2342 1A/B-1 FEB 3,1923 (74)
PrimCare: CPRSProvider, Three PCTeam: GOLD
Item Ordered Requestor Start Stop Sts
1 CT ABDOMEN W&W/O CONT *UNSIGNED* | CPRSPROVIDER,ONE unr
2 Discontinue CBC BLOOD WC LB# 269 | CPRSPROVIDER,TWO unr
*UNSIGNED* |
3 Change SODIUM SERUM SERUM WC to GLUCOSE | pend
SERUM SERUM SP LB# 242 *UNSIGNED* |
4 Change GLUCOSE SERUM SERUM SP to | pend
POTASSIUM SERUM SERUM SP LB# 242 |
*UNSIGNED* |
Enter the numbers of the items you wish to act on. >>>
+ Next Screen - Previous Screen Q Quit
Select:Quit// Quit
2. The Consult Service Gets a Written Copy
The consult service receives an alert and a printed SF 513. The Consultation Form is automatically generated in the receiving clinic when the requesting physician signs the order. (In the case of Inter-Facility Consults, the request in routed to the resulting facility and printed there.)
Caution: The Consultation Form (SF 513) generated by this package for use by the receiving services is highly confidential and should be treated with the same security precautions as other patient medical record documents.
The computerized consultation form created and printed by this package may only be placed in a patient’s medical record, as a valid medical form, if it has been authorized for medical record use by the Medical Records Committee at your facility.
--------------------------------------------------------------------------------
MEDICAL RECORD | CONSULTATION SHEET
--------------------------------------------------------------------------------
CPRSPATIENT,NINETY
XXX-XX-9200 02/03/1904 NSC VETERAN
CV ELIGIBLE
--------------------------------------------------------------------------------
Consult Request: Consult |Consult No.: 10943
--------------------------------------------------------------------------------
To: CARDIOLOGY
From: 2B MED |Requested: 08/24/2009 11:00 am
--------------------------------------------------------------------------------
Requesting Facility: BOISE |ATTENTION: CPRSPROVIDER,SEVEN
================================================================================
REASON FOR REQUEST: (Complaints and findings)
Patient has a Hx of hypertrophic cardiomyopathy Dx'ed 3 years ago and
seems to be somewhat stable. Lung fields appear slightly edematious on
Chest X-Ray and we need an assessment of cardiac function prior to
increasing Digitalis dosages.
--------------------------------------------------------------------------------
PROVISIONAL DIAG: Cardiomyopathy, Hypertrophic (425.1)
--------------------------------------------------------------------------------
REQUESTED BY: |PLACE: |URGENCY:
C PRSPROVIDER,TEN |Bedside |Routine
PHYSICIAN | |
(Pager: ) |SERVICE RENDERED AS: | Clinically Indicated
date:
(Phone: ) |Inpatient | Jan 31, 2011
--------------------------------------------------------------------------------
W O R K I N G C O P Y
No Consultation Results available.
================================================================================
AUTHOR & TITLE: |
|DATE:
--------------------------------------------------------------------------------
ID #:_______|ORGANIZATION: BOISE |REG #:____ |LOC: 2B MED
--------------------------------------------------------------------------------
Standard Form 513 (Rev 9-77)
3. If Accepted, an Appointment is Held
It is fairly common for a consult to be sent to the wrong clinic. For this reason it is very easy to forward a consult to another clinic. Simply use the FR (Forward Request) action to specify the new receiving clinic.
In this example, a Neurology consult is forwarded to Psychiatry at the discretion of the consulting physician:
Select OPTION NAME: ORMGR OE/RR Manager Menu menu
You have PENDING ALERTS
Enter "VA VIEW ALERTS to review alerts
Select OE/RR Manager Menu Option: VA View Alerts
1.I CPRSPATIE (C3779): Critical High Lab: LITHIUM 5 02/06 10:51
2. ARTPATIEN (A9600): New Consult/Request (Today)
Select from 1 to 12
or enter ?, A I, F, P, M, R, or ^ to exit: 2
Consult/Request Alerts Feb 13, 1999 13:06 Page: 1 of 1
CPRSPATIENT,TWELVE 666-24-3779 1A/B-1 FEB 3,1923 (74)
Ward: 2B MED
Requested St No. Consult/Procedure Request
185 02/12/97 p 1636 NEUROLOGY Consult
Enter ?? for more actions
RC Receive CM Add Comment DD Detailed Display
FR Forward CT Complete/Update RT Results Display
CX Cancel (Deny) MA Make Addendum PF Print Form 513
DC Discontinue SC Schedule
Select Action: Quit// FR Forward Consult
Forward Request To Another Service For Action.
Select the service to send the consult to.
Forward Consult to which Service/Specialty: PSYCHIATRY
Who is responsible for Forwarding the Consult: CPRSPROVIDER,SEVEN CS HYN
Actual Date/Time of Activity: NOW// (Feb 13, 1999@14:24)
Urgency: Today// Today
Enter COMMENT:
1> List of symptoms indicates Psychiatry would give better work up.
2>
EDIT Option:
(Continued on the next page.)
Consult/Request Alerts Feb 13, 1998 13:07 Page: 1 of 1
CPRSPATIENT,TWELVE 666-24-3779 1A/B-1 FEB 3,1923 (74)
Number Date Stat Service Procedure
185 02/12/97 p PSYCHIATRY Consult
Enter ?? for more actions
RC Receive CM Add Comment DD Detailed Display
FR Forward CT Complete/Update RT Results Display
CX Cancel (Deny) MA Make Addendum PF Print Form 513
DC Discontinue SC Schedule
Select Action: Quit//
Receive the Consult
Performing the Receive action on a consult changes its status from Pending to Active. This puts your clinic on record as accepting responsibility for completing the consult.
There are two ways to receive a consult:
From a consult tracking screen.
From a notification alert of a new consult. See page 129 for an example of this method.
In the following example, we receive a consult from a consult tracking screen:
CONSULT TRACKING Oct 05, 2000 09:18:22 Page: 1 of 1
CPRSPATIENT,TWELVE 666-24-3779 1A/B-1 FEB 3,1923 (74)
Wt.(lb): No Entry
Requested St No. Consult/Procedure Request
1 05/06/97 p 226 PSYCHIATRY Cons
Enter ?? for more actions
SP Select Patient FR Forward CT Complete/Update RT Results Display
CV Change View ... CX Cancel (Deny) MA Make Addendum PF Print Form 513
RC Receive DC Discontinue SF Sig Findings RM Remove Med Rslt
SC Schedule CM Add Comment DD Detailed Display ER Edit/Resubmit
Select: Quit// RC Receive Request
Who received it?: CPRSPROVIDER,SEVEN CS
Date/Time Actually Received: NOW// (NOV 01, 1997@09:05)
Enter COMMENT...
1>Pt will be seen ASAP
2>
EDIT Option:
CONSULT TRACKING Oct 05, 2000 09:18:22 Page: 1 of 1
CPRSPATIENT,TWELVE 666-24-3779 1A/B-1 FEB 3,1923 (74)
Wt.(lb): No Entry
Requested St No. Consult/Procedure Request
1 05/06/97 a 226 PSYCHIATRY Cons
Enter ?? for more actions
SP Select Patient FR Forward CT Complete/Update RT Results Display
CV Change View ... CX Cancel (Deny) MA Make Addendum PF Print Form 513
RC Receive DC Discontinue SF Sig Findings RM Remove Med Rslt
SC Schedule CM Add Comment DD Detailed Display ER Edit/Resubmit
Select: Quit//
4. Results are Entered and Signed
The consult service enters results and comments. When you request the Complete (CT) action from the Consults service tracking or CPRS Consults screen, VISTA shifts you into TIU.
In the following example, we complete a consult and enter findings through Consult’s link to TIU:
Select Consult Service Tracking Option: CS Consult Service Tracking
Select Patient: CPRSPATIENT,TWELVE 05-05-55 666553779 YES SC
VETERAN
Select Service/Specialty: ALL SERVICES// PULMONARY
List From Starting Date: ALL DATES // ALL DATES
CONSULT TRACKING Oct 05, 2000 09:22:45 Page: 1 of 1
CPRSPATIENT,TWELVE 666-24-3779 1A/B-1 FEB 3,1923 (74)
Wt.(lb): 180
Requested St No. Consult/Procedure Request
1 09/04/97 p 319 PULMONARY Cons
Enter ?? for more actions
SP Select Patient FR Forward CT Complete/Update RT Results Display
CV Change View ... CX Cancel (Deny) MA Make Addendum PF Print Form 513
RC Receive DC Discontinue SF Sig Findings RM Remove Med Rslt
SC Schedule CM Add Comment DD Detailed Display ER Edit/Resubmit
Select: Quit// CT Complete
CHOOSE No. 1-2: 1
Creating new progress note...
Patient Location: 2B
Date/time of Admission: 10/05/00 09:22
Date/time of Note: NOW
Author of Note: CPRSPROVIDER,SEVEN
...OK? YES//
Calling text editor, please wait...
==[ WRAP ]==[ INSERT ]===< Patient: CPRSPATIENT,TWELVE >===[
H=Help ]===
Mr. CPRSPatient’s regimen is lacking in inhaled corticosteroids. Recognizing
that asthma is an inflammatory process, inhaled steroids are important
in controlling the inflammatory response. My practice for severely
out-of-control asthmatics is to use high-dose inhaled steroids,
typically vanceril, 16 puffs qid, with a spacing device such as the
Aerochamber. I would institute such a regimen while he is here.
Mr. CPRSPatient has an in-house pet dog and an outside pet cat. I have
told him that the cat should go, even if it is outdoors. Cat saliva
contains a glycoprotein that leaves residue on their coats and flakes
into the air; it is problematic for many asthmatics.
The purulent phlegm asthmatics have during exacerbations is usually
due to the eosinophils, not from infection. Antibiotics are usually
not necessary.
If you like, you may refer Mr. CPRSPatient to my clinic after discharge.
<======T=======T=======T=======T=======T=======T=======T=======T=======T=>=====T
(Continued on next page.)
Saving MEDICINE CONSULT with changes...
Enter your Current Signature Code: SIGNATURE VERIFIED..
Print this note? No// Y YES
Do you want WORK copies or CHART copies? CHART//
DEVICE: HOME// WORK OTC
DO YOU WANT YOUR OUTPUT QUEUED? NO// Y (YES)
Requested Start Time: NOW// (Oct 05, 2000 09:23:05)
Request Queued!
CONSULT TRACKING Oct 05, 2000 09:23:45 Page: 1 of 1
CPRSPATIENT,TWELVE 666-24-3779 1A/B-1 FEB 3,1923 (74)
Wt.(lb): 180
Requested St No. Consult/Procedure Request
1 09/04/97 c 319 PULMONARY Cons
Enter ?? for more actions
SP Select Patient FR Forward CT Complete/Update RT Results Display
CV Change View ... CX Cancel (Deny) MA Make Addendum PF Print Form 513
RC Receive DC Discontinue SF Sig Findings RM Remove Med Rslt
SC Schedule CM Add Comment DD Detailed Display ER Edit/Resubmit
Select: Quit//
5. The Originating Clinician Receives an Alert that the Consult is Complete
After the consult is complete, Notifications sends an alert (via FileMan Alerts) of the completion. This is done while you are in the menu terminal mode, as such:
CPRSPATIE (C8829): Completed Consult CAR
TIUPATIEN (T2342): Cancelled consult PLM
ARTPATIEN (A9898): Completed Consult GASTROENTEROLOGY
CPRSPATIE (C8831): Completed Consult PLM with Sig Findings
Enter "VA VIEW ALERTS to review alerts
Select Consult Service Tracking Option:
To receive an on-screen report of the results, respond as in the following example:
Select Consult Service Tracking Option: VA View Alerts
1. CPRSPATIE (C8829): Completed Consult CAR
2. TIUPATIEN (T2342): Cancelled consult PLM
3. ARTPATIEN (A9898): Completed Consult GASTROENTEROLOGY
4. CPRSPATIE (C8831): Completed Consult PLM with Sig Findings
Select from 1 to 4
or enter ?, A I, F, P, M, R, or ^ to exit
or RETURN to continue: 3
Processing alert: TIUPATIEN (T8829): Completed Consult PLM
Consult/Request Alerts Feb 26, 1999 14:56:57 Page: 1 of 1
TIUPATIENT,TWELVE 666-24-2342 1A/B-1 FEB 3,1923 (74)
Wt.(lb): No Entry
Requested St No. Consult/Procedure Request
1 01/08/99 c 1337 PULMONARY Cons
Enter ?? for more actions
SP Select Patient FR Forward CT Complete/Update RT Results Display
CV Change View ... CX Cancel (Deny) MA Make Addendum PF Print Form 513
RC Receive DC Discontinue SF Sig Findings RM Remove Med Rslt
SC Schedule CM Add Comment DD Detailed Display ER Edit/Resubmit
Compiling Result Display...
(Continued on next page.)
Here we select the Results Display (RT) action:
Results Display Feb 26, 1999 14:59:10 Page: 1 of 1_
TIUPATIENT,TWELVE 666-24-2342 1A/B-1 FEB 3,1923 (74)
Consult No.: 1337 Wt.(lb): No Entry
------------------------------MEDICINE CS CONSULT------------------------------
Pt should stay away from Oyster Crackers.
Signature: /es/CPRSPROVIDER,SEVEN Date: FEB 12, 1999@11:35:14
Source Information
Document Status: COMPLETED
Entry Date: FEB 12, 1999@11:32 Author: CPRSPROVIDER,S
Expected Signer: CPRSPROVIDER,SEVEN Expected Cosigner: None
Entered By: CRS TIU Document #: 5365
Urgency: None
================================================================================
Enter ?? for more actions
Select Action: Quit//
6. The SF 513 Report Becomes Part of the Patient’s Medical Record
After the consult is complete, Consults sends an alert to the requesting physician. The requesting physician can use the Print Report action to obtain a copy of the final Consults report. In the following example, the consult we want to print has already been selected:
CONSULT TRACKING Feb 13, 1998 13:20:44 Page: 1 of 1
CPRSPATIENT,TWELVE 666-24-3779 1A/B-1 FEB 3,1923 (74)
Wt.(lb): 178
Requested St No. Consult/Procedure Request
1 11/01/97 c 675 PULMONARY Consult
2 10/28/97 a 506 Consult
3 07/21/97 c 285 PULMONARY Pulmonary Function Test
Enter ?? for more actions
SP Select Patient FR Forward CT Complete/Update RT Results Display
CV Change View ... CX Cancel (Deny) MA Make Addendum PF Print Form 513
RC Receive DC Discontinue SF Sig Findings RM Remove Med Rslt
SC Schedule CM Add Comment DD Detailed Display ER Edit/Resubmit
Select: Quit// PT Print Form
Chart Copy (Y/N) Y//
DEVICE: HOME// ;;9999 HOME
(Continued on next page)
--------------------------------------------------------------------------------
 MEDICAL RECORD | CONSULTATION SHEET
--------------------------------------------------------------------------------
CPRSPATIENT,FOUR SERVICE CONNECTED 50% to 100%
XXX-XX-4442 03/03/1960 SC VETERAN
123 SESAME ST.
APT. 4
SALT LAKE CITY UTAH 84101 Phone: 801-555-1289
--------------------------------------------------------------------------------
Consult Request: Consult |Consult No.: 675
--------------------------------------------------------------------------------
To: PULMONARY
From: NOT 2B |Requested: 11/01/1997 10:13 am
--------------------------------------------------------------------------------
Requesting Facility: ELY |ATTENTION: CPRSPROVIDER,TWO ================================================================================
Current Primary Care Provider: CPRSPROVIDER,SEVEN
Current Primary Care Team: GOLD TEAM
REASON FOR REQUEST: (Complaints and findings)
Pt experiences shortness of breath when out of bed.
--------------------------------------------------------------------------------
PROVISIONAL DIAG: CHEESE HANDLER’S LUNG
--------------------------------------------------------------------------------
REQUESTED BY: |PLACE: |URGENCY:
CPRSPROVIDER,SEVEN |Bedside |Routine
Chief of Surgery | |
(Pager: 9999) |SERVICE RENDERED AS: |
(Phone: 1234) |Inpatient |
--------------------------------------------------------------------------------
W O R K I N G C O P Y
CONSULTATION NOTE #2330
TITLE: PULMONARY CS CONSULT
DATE OF NOTE: NOV 01, 1997@10:15:35 ENTRY DATE: NOV 01, 1997@10:15:35
AUTHOR: CPRSPROVIDER,SEVEN EXP COSIGNER:
URGENCY: STATUS: COMPLETED
At the time I went to examine the pt, he was acutely broncho-
spastic and in moderately severe respiratory distress. I had him
deliver a puff of albuterol with an Aerochamber; his technique was
poor. I then instructed him and delivered an additional four puffs,
which he did with good technique. He was improved and with a clear
lung exam within a few seconds (though wheezes were still present
on forced expiration).
The pt regimen is lacking in inhaled corticosteroids. Recognizing
that asthma is an inflammatory process, inhaled steroids are important
in controlling the inflammtory response. My practice for severely
out-of-control asthmatics is to use high-dose inhaled steroids,
typically vanceril, 16 puffs qid, with a spacing device such as the
Aerochamber. I would institute such a regimen while he is here.
/es/ CPRSPROVIDER,SEVEN
Signed: 11/01/1997 10:17
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PROVISIONAL DIAG: Arrhythmia (427.9)
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REQUESTED BY: |PLACE: |URGENCY:
CASEY,BEN |Bedside |Routine
CHIEF OF SURGERY | |
(Pager: ) |SERVICE RENDERED AS: |CLINICALLY INDICATED DATE:
(Phone: ) |Inpatient |Jan 31, 2011
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See page 126 for details on the Print Report (PR) action.
Dostları ilə paylaş: | 
