Posts Tagged triage nurse

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How My Practice Knew We Were Ready for EMR

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My current practice is getting ready to go live on Electronic Medical Records (EMR) in just two short months, but it’s taken us over a year to get here.  When I first started this job, we were supposed to go live with EMR in two months.  After I’d had a chance to speak with everyone, I just knew the timing wasn’t right for the EMR.  We would need to be able to run, and at that moment we were just starting to crawl.

What were the signs we weren’t ready?

  • communication problems with the vendor, who provided the existing practice management system and the new EMR
  • issues with the practice management system which had been mis-identified as being support-related
  • basic decisions had not been made: one shared medical record for all clinics or individual records for each clinic?
  • no single point person who was keeping everything together
  • lots of frustrated and worried faces – did we know what we were doing?

A sigh of relief…

Although we knew we wanted the EMR and we had already made the investment, we also knew it might be a train wreck if we didn’t get some other questions answered first.  When I announced we were going to delay the go-live until we had some other issues resolved, there was a sigh of relief from all involved.

What did we do to get ready for EMR?

  1. We attacked the support problems by rerouting all support issues through one person – me.  I kept a detailed log of all support issues and the resolution of each.  I found the vendor to be surprisingly helpful and issues relatively easy to resolve.  As I asked questions and we fixed issues, we found that much of our problem was training-related.
  2. We held a major training event where all non-clinical staff were retrained to use the practice management system and everyone was given new cheat sheets for the correct way to use the system.
  3. We realized that staff were worried about the impact of the EMR because the providers were overwhelmed with the current workload.  They didn’t know how we would get through the pre-live work, the huge challenge that is the go-live and first few months of adjustment.  After some intense evaluation, we changed our scheduling strategy and moved established visits from 15 minutes to 20 minutes, adding four work-in appointments and setting rules for adding more than four work-ins.
  4. We took the vitals out of the halls and into the exam rooms, making the office quieter and the patient interactions private.
  5. We also got control of most of our paper processes that weren’t working.  We color-coded messages, re-educated patients about new ways of communicating with us and we managed to bring our fax and phone call volumes down to a manageable number.
  6. We assigned nurses to the providers and asked the provider-nurse duos to put their arms around their patient panels as a team.  The patients love it.  We moved a float nurse to a triage nurse position to start taking all requests for same day sick visits and scheduling them appropriately.
  7. We are soon to add an answering service (I prefer the term “virtual receptionist”) to our phones.  The virtual receptionists (1000 miles away!) will take calls for the nurses and providers, typing them directly into our EMR.
  8. We also started a front-end collection system, bringing our accounts receivable under control by adding automated eligibility, a new financial policy, collecting co-pays at check-in, calling patients with old balances before they arrived for their visit, and instituting a discount for non-insured patients.

How will you know when your practice is ready for EMR?

  • You are not overwhelmed on a day-to-day basis.  If your practice isn’t running well without an EMR, it is not going to run better with an EMR.  If you are having operational issues, consider having a consultant help you set up new processes to handle the hurdles you’re facing now.  The EMR does not fix operational issues, with the possible exception of lost paper charts.
  • Your staffing is stable.  There will always be some employees coming and going, but if you are experiencing one of those cyclical shifts when you have several new staff at once (especially nurses), you might want to give them a little more time to get a handle on their jobs before introducing EMR.
  • You have your practice management act together – your PM works well and is up-to-date.
  • Your finances are in order.  If it takes several months of lower productivity, followed by less collections, you can weather the storm because you are on top of the dollars.

Posted in: Day-to-Day Operations, Electronic Medical Records

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Who Does What in a Medical Office: Basic Position Descriptions

Front Desk/Check-In

  • Greets patients and visitors to the practice
  • Registers patients in the practice management system which may mean entering information given verbally or on registration forms
  • Collects identification and insurance cards and copies or scans them for the record, may photograph the patient for the record
  • May collect co-pays or other monies
  • Prints encounter form (also called superbill, routing slip, or fee ticket) with updated information, or updates information on the encounter form
  • Has patient sign financial agreement, receipt of privacy policy, benefits assignment, etc.
  • May answer phone calls, take messages and make appointments
  • Directs visitor (drug reps, salespersons, etc.) appropriately

Medical Records

  • Primary responsibility for the integrity and management of the medical record, whether paper or electronic
  • Controls record filing (paper) or indexing (electronic)
  • Fulfills requests by patients, attorneys, insurance companies, and social security for release of records
  • May manage paper faxes and messages by attaching to charts and delivering to provider
  • May prepare paper charts for chart audits by payers or others
  • May be the HIPAA Officer

Medical Assistant, LPN or RN

  • May assist Physician, Nurse Practitioner or Physician Assistant with procedures
  • Depending on state laws, may give injections
  • May perform procedures independently (ear wax removal, staple removal, etc.)
  • Provides Medicare patients with an Advance Beneficiary Notice if any lab test or procedure to be performed in the office will not be covered by Medicare
  • May perform phlebotomy (draw blood)
  • May collect specimens, perform basic laboratory tests and chart results
  • Provides patient education verbally and by providing written materials
  • May schedule tests or procedures ordered by the provider
  • May schedule surgery and prepare surgery packets for providers (*this may be delegated to a surgery scheduler if this position exists)
  • Calls patients about test or procedure results; returns patients calls with answers after consulting with provider
  • Prepares exam room for procedures (PAP smears, excisions, etc.), marks specimens for lab and pathology
  • Cleans exam room after each patient and stocks exam and procedure rooms with supplies
  • May be responsible for ordering office medications and medical supplies
  • May perform lab controls daily and check and record temperatures on lab refrigerators and freezers

Triage Nurse

  • Takes incoming calls from patients and gives them medical advice according to predetermined nursing protocols
  • Makes decisions about patients needing to be seen urgently, same day or next day
  • May be delegated callbacks from providers or other nurses
  • May see walk-in patients and triage their condition

Lead Nurse, Charge Nurse, or Nurse Supervisor

  • Assigns clinical staff specific responsibilities
  • Manages clinical staff schedules, using agency or temporary staff as needed
  • Performs annual competency exams on staff
  • Ensures all staff are current on licenses, continuing education and CPR
  • Problem-solves patient issues
  • May be responsible for ordering office medications and medical supplies
  • Has responsibility for medication sample closet upkeep
  • May perform annual evaluations fro clinical staff
  • Responsible for equipment maintenance and makes recommendations for medical equipment as needed
  • May be the Patient Safety Officer and the Worker’s Compensation Coordinator

Referral Clerk

  • Reviews orders written by providers and determines where test and procedures may be performed based on patient’s insurance
  • May provide the patient with information about the test or procedure cost and what the patient’s financial responsibility is estimated to be
  • Pre-authorizes, pre-certifies, or pre-notifies the test or procedure if required by the patient’s insurance company
  • Schedules the test or procedure
  • Provides the patient with information about preparation for the test or procedure

Lab Technologist/ Phlebotomist

  • Receives laboratory requisitions from provider and collects specimens according to provider order
  • Provides Medicare patients with an Advance Beneficiary Notice if any lab test or procedure to be performed in the office will not be covered by Medicare
  • Performs tests or packages specimens to be transported to reference lab
  • Receives results back from the labs and matches them to charts
  • Performs lab controls daily and checks and records temperatures on lab refrigerators and freezers

Check-out Desk

  • Reviews services received by patients, checking to make sure that all services received were checked on the encounter form
  • Enters charges in the computer system for services received
  • Tells patient if any additional monies are owed if co-pay was collected at check-in
  • May sign patient on to a payment plan if needed
  • Takes monies owed, posts monies and produces a receipt for the patient
  • Makes return appointment for the patient if needed, or enters recall into the practice management system

Biller or Collector

  • Corrects claims that are rejected from the claims scrubber, clearinghouse or payer
  • Files secondary and tertiary claims as needed, electronically or via paper
  • Posts receipts from insurance companies and patients and edits any electronic remittance advice; may post from lockbox account on the web
  • May prepare deposits and/or make deposits
  • Generates patient statements
  • May check eligibility on patients with appointments and call patients whose insurance is not active (*may be delegated to a financial counselor if this position exists)
  • Calls patients who have not made payments in response to statements
  • May turn patients over to third-party collectors
  • Takes phone calls from payers or patients about billing issues and resolves issues

Coder

  • Reviews notes from inpatient or outpatient encounters and codes them according to the documentation
  • May post charges for services rendered
  • Audits chart documentation for quality purposes to ensure that provider coding and documentation is synchronous
  • Introduces changes in procedure (HCPCS) and diagnosis (ICD-9) codes and educates staff on the use of new codes
  • Ensures encounter forms and practice management software is updated appropriately with new and deleted codes
  • May be delegated the Compliance Officer

Billing Supervisor

  • Reviews the work of coders, billers and collectors and performs quality audits to benchmark acceptable error rates
  • Prepares or reviews deposits and tracks daily charge, collection, write-off and deposit information, watching for monthly abberations by payer or date
  • Reviews Accounts Receivable (A/R) reports, looking for trending or specific problems to be addressed with staff or payers
  • Brings to the attention of the Office Manager or Administrator any issues with non-standard payment trends, denials or non-covered services.
  • Performs evaluations for billing department staff
  • Takes escalated patient complaints
  • May credential providers with new payers or recredential providers with payers or hospitals

Office Manager, Practice Administrator, or Practice Manager (see the Library tab for job descriptions) see my posts on what an administrator does here, and a day in the life of an administrator here

  • Performs all human resource functions for the practice
  • Has ultimate responsibility for all money flowing in and out of the practice – makes deposits, pays bills, etc.
  • Contact person for all computer system, equipment and phone system issues
  • Responsible for day-to-day operations, advises supervisors on issues and problems
  • Resolves escalated patient complaints
  • Meets with vendors and researches possible practice purchases
  • Negotiates all practice contracts
  • Meets with staff and providers on a regular basis

These descriptions will not perfectly fit most practices, this is just a generalization.  Each practice divides duties based on the number and skills of the staff in their office, and their specialty.  These descriptions should help to define what the basic tasks are in most practices.

Posted in: Day-to-Day Operations, Human Resources

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