Encounter Records
Two sets of records on a patient's MedKaz contain vital information about their current and past health. One is the set of current documents displayed for you in a Document Viewer when you log on to your patient's MedKaz. The other is the list of encounter records in your patient's Encounters tables which also can be displayed in the Document Viewer.
You can use them to help diagnose and treat your patient's current problems, avoid unnecessary or redundant tests, improve the quality of care you deliver, and coordinate your care with the care provided your patient by others.
Current Documents
When you log on, at least two and perhaps four key documents are displayed in an Encounter Folder in the Document Viewer. They give you, in concise form, current information about your patient's health that you otherwise must spend time trying to elicit, thereby freeing you to talk with your patient about their problems. Together with any other documents relating to the encounter, these documents become part of the complete encounter record stored permanently in the Encounters Table.
Referral Request
If your patient has been referred to you, a Referral Request prepared by the referring care provider is displayed. It contains the referring provider's primary diagnosis, request, and related ICD-9 CM code. By having it on your patient's MedKaz, you do not have to pursue the referring provider to send it to you. You can treat your patient and send the Request to your patient's insurance company for payment.
Pre-Visit Questionnaire
If your patient, as instructed, has completed the Pre-Visit Questionnaire accessible from his or her MedKaz, a Pre-Visit Questionnaire report is included in the Encounter Folder, to be opened in the Document Viewer. Drawing from Primetime Medical's Instant Medical History, it describes their complaints in depth in clinical terms, saving you precious time.
Health Summary Report
A comprehensive Health Summary Report is generated from your patient's MedKaz every time you log on. This unique document gives you an up-to-the-minute snapshot of your patient's past and current health, including:
- Patient information, including a photograph for identification
- Reason/Chief Complaint for visit
- Past Illnesses, Surgeries, and Chronic Conditions
- Medical Devices
- Medications your patient is actually taking
- Medications prescribed for your patient
- Allergies
- Immunizations
- Recent Encounters - If the patient is a regular patient, this list includes care providers your patient has seen since they last saw you. If this is the first time you are seeing this patient, the list includes every care provider the patient has seen in the preceding six months.
Encounter Summary
A partially pre-populated Encounter Summary also is generated from your patient's MedKaz every time you sign on. It is a critical, easy-to-use working document you complete for each encounter. It provides the indexing data that enable you to turn paper records into sortable and searchable electronic documents that along with other electronic documents can be managed on your patient’s MedKaz. It is a working document you use to:
- Record and store your progress notes
- Record your patient's vital signs (the Server calculates their BMI)
- Add or drop medications
- Record allergies and immunizations
- Note the Body Locations and Body Systems applicable to the visit
If your patient completed the Pre-Visit Questionnaire, the Reason/Chief Complaint will be pre-populated. If not, you must fill it in. In either case, you should fill in the Assessment field. This information is needed to populate key fields in the Encounters > Providers Table on the MedKaz.
You can attach other documents such as transcribed progress notes to the Encounter Summary by printing them out and having your assistant scan and upload them to the Server.
The Encounter Summary can be filled out on your computer or printed out and completed by hand. If you are interrupted before you complete it, click Finish Later to save it to your PRM along with all the contents of the Encounter Folder.
Prior Encounters Documents
Each row in the Encounters > Providers Table represents a single encounter your patient previously had with a care provider. They initially are displayed in descending order by date but can be re-sorted by clicking on any of the table's column headings. This enables you to sort encounters into logical groupings such as all encounters concerned with specific Body Locations or Body Systems. The Encounters > Tests-Labs Table functions the same way.
When you click on a specific row, all documents relating to that particular encounter - whether created initially as paper or electronic documents or both - are listed for you to read in the Document Viewer. They include: the Referral Request and Pre-Visit Questionnaire Report if available for the encounter, and the Health and Encounter Summaries, plus any others such as a copy of handwritten or transcribed progress notes, documents your patient may have given you, etc. In the case of hospital visits, the documents include the discharge report, operative report if there is one, consult notes, and test results.
All documents are captured in the uploading and verification process, thereby preserving a complete record of the encounter. You or other providers can read these complete records in the Document Viewer to fully understand the problems presented, the alternative diagnoses considered and the prescribed treatment.