|Note: Nurse only visits can include appointment reasons such as patients coming in for shots, weight checks, rechecks etc. These visits can be documented as encounters in Office Practicum.|
Steps to Document a Nurse Only Visit
- Open an encounter note.
- Apply Template.
|Note: If prompted to apply a template (i.e. "Shot" template), click yes to apply the template. If you are not prompted, search for the template.|
- To search for a template, type in the search field.
- In the example below, the words shot only visit are typed in the search field.
- The system pulled up the shot only visit template.
- Click on OK to apply the template.
- In the Chief Complaint (CC) section, document the vaccines/shots to be given on the visit.
- As part of the template, the Review of System information is automatically applied.
- So far we have documented the reason for the visit, and the review of systems. We now just need to document the shots given.
- Click on the Assess/Plan tab.
- Click on the Imm tab.
- Review the patient's vaccine on the yellow section at the bottom.
- To view the full vaccine record, double-click on the yellow section or click on the syringe icon. The patient's vaccine record will open.
- Click in field under vaccine name to begin building your vaccine order list.
Click on Green Plus icon in lower left corner to add more than one vaccine to your list.
- Click the Green Check icon .
- Click on the Do Now button .
- Immunization Order Management Window Open.
- Double-Click on the vaccine you are administering.
- In the example below, I 'double-clicked' on line for HepA.
- The "Enter Vaccine Administration Information" window displays.
- Confirm the Vaccine information: Manufacturer, Expiration date, and Lot number.
- Choose Body Site from the drop down.
- Check over the information on the window.
- Leave counseling provider blank on a nurse only visit if no provider counsels the patient. (be sure to check with your supervisor on your policy regarding counseled and non-counseled vaccines).
- Click on Ignore in this situation.
- Click Save when complete.
|Filling out the window and clicking Save will:|
|Make sure to check the lot# on the vaccine vial, against the lot# listed in Office Practicum. If the lot# does not match, "cancel" out of this window.|
Make sure to check Allergies and Reactions at the top of the window.
- Click on Coding.
- Click on Use Suggested CPT.
- Click on Summary.
- Click on Finalize then OK.