Hello, my name is Leslie Jones-Larsen, and today we'll be talking about chart preparation, preparing for the patient visit. We're going to go through admission and discharge via the hospital, chart prepping for new patients, follow-up patients, and any subspecialty considerations that we want to take into account. When chart prepping, it's really important to know if the patient has been admitted and discharged from the hospital since their last clinic visit. The team will need to get records from the recent hospitalization. Usually, you can sort of categorize these records coming in three different ways to the clinic. One is if the patient was seen within the same health system, you can review the electronic medical record and make sure the relevant cardiac studies and notes are available and completed within the record. If they aren't, you can always send a message to that provider or the patient's care team to see if they can be completed before the visit. The second bucket is really around if the patient was seen at another facility and potentially that facility was using Epic as well, you can check care everywhere. You'll need to know the facility name and you'll need to know which relevant cardiac studies and notes you're looking for, and then you can download them and make them available specifically in your chart that you're accessing. And if neither one of these options are available, you can go back to just giving a phone call to the specific hospital and asking for the medical records department and asking for all relevant cardiac studies and notes within a specific time period of the admission and the discharge. Things that you'll want to consider are the admission history and physical that was taken, any consultation notes, both on the cardiac side as well as if there was any surgeons, procedure notes, this is where you would potentially see things from your interventional cardiologist or your heart failure team or maybe even your valve team, and then your discharge summary. When prepping for the new patient, it's really important to remember that the patient intake form is really key to the ambulatory visit. These intake forms can be sent in multiple ways depending on how your clinic specifically does it, and you can ask your preceptor about that. But the paper forms usually are sent to the patient when the new patient visit is scheduled. If you're more sophisticated in that, potentially the electronic form was sent through a patient's MyChart account if you're using Epic. Or you might be using a combination of those two things where you sent a paper form, the paper form came back to your clinic, and you're using a telephone encounter to pre-populate the electronic medical record with details. Or you might be just doing it the old-fashioned way and calling the patient and gathering the information through a telephone encounter. No matter which way you're using, though, it's also important to collect the PCP information or primary care physician or provider. You'll want to request the reason for the referral, symptoms, and or diagnosis. Sometimes you can find this on the referral note, but sometimes you have to go back to the chart note where the referral was created to get all this information. You may also be looking for records that include any testing. Sometimes this could be lab testing. Maybe they sent the patient for a stress test. Maybe they sent them for some diagnostic imaging. And potentially they sent the patient to other providers within the cardiovascular team, or maybe they sent them to other specialists too. Potentially they might have gone to GI. Maybe they went to pulmonary. So you'll want to make sure that you have that whole comprehensive look at the primary care provider's records as well as any referring providers. And then the last component of this new patient record collection is making sure if they did have any cardiac procedures or diagnostics before their cardiac visit that we have all the details. Maybe they had an EKG tracing. Maybe it was in their primary care provider's office. Maybe it was in a specialist's office. Maybe it was just at the hospital. So you'll want to get those EKG tracings. And your clinic and your preceptor will be able to tell you how many of the tracings or how far you want to go back to get them. The second would be if they've had any monitors. In the EKG module you learned about both the Holter and event monitors. So this is where you'd want to make sure that you have those tracings. And then third, if a device is implanted, maybe a pacemaker, ICD, loop recorders, you'll want to make sure that you have those reports available as well and the most recent interrogation. And that interrogation should include the tracings. So this can take some time to track all this information down for your new patients, which is why you're starting early before the visit. And they might have had other pieces of the puzzle too here. So you'll want to make sure did they have any heart procedures if they were in the hospital, like a CABG or open heart surgery, a cath or a PCI intervention, or maybe they had an EP procedure. Also those diagnostic tests we talked about, but definitely the ECHOs or a NUC or a CT scan. And then making sure you're looking for all those subspecialties in the cardiology realm. The general cardiologists, maybe the cardiothoracic surgeons, the vascular surgeons, etc. If you're prepping the chart for follow-up patients, you may or may not get an easy one. For the follow-up patients, you want to make sure that you review the provider's last outpatient visit and understand what items needed to be completed before the next visit. You need to inventory to see if there's any outstanding visits, any diagnostics that have been completed, when they were done and where they were done, and assure that you have all the records appropriate for review. For follow-up patients, you also need to get back with that primary care provider or the referring provider to make sure you have any of those notes if it's been within the last year since they've seen cardiology. And then you can't forget all the recent cardiac procedures and diagnostics that you may need to collect. This is the one that probably will take the longest. The EKG tracings, any monitor tracings, and then that device implant. And you need more than just the report. Remember, you need the interrogations that include the tracings. And last but not least, you'll want to make sure that you have all the other cardiology considerations in place. The generalists, the interventional team, the valve team, the advanced heart failure team, EP team, and the cardiac and vascular surgeons. You'll want any notes from them, both consultative in the clinic as well as procedures done within the hospital. This really concludes chart prep. Remember, both for the hospital piece of the puzzle as well as both for new patients and follow-up patients in the clinic. If you have any questions that are specific to your clinic, you should really talk to your preceptor. But you also can reach out to the MedAxiom Academy.

chart preparation

patient visits

obtaining records

hospitalizations

comprehensive patient care