Administrative Clinical Support

Overview

This section covers the administrative technologies that support clinical care, including EHR systems, prescription management, and durable medical equipment.

1. Electronic Health Records (EHR) & Charting

• CPOE (Computerized Physician Order Entry): Allows providers to order meds/labs directly. Primary Benefit: Reduces errors (illegible handwriting).
• Charting Timing: Document immediately after the procedure. Never batch chart or pre-chart.

2. Prescription Management

Transmission Methods

• E-Prescribing: Electronic transmission to pharmacy. Safest method.
• Controlled Substances:
  • Schedule II: High abuse potential. No refills.
  • Schedule III-V: Can have 5 refills in 6 months. Can be phoned in.

The "Copy Only" Rule

If a patient asks for a physical copy of a script that was already sent electronically, write "Copy Only" to prevent duplicate filling.

3. Telehealth and DME

• Telemedicine: Remote clinical care (video visits).

• Emergency Protocol: If a patient reports life-threatening symptoms (e.g., crushing chest pain, severe shortness of breath) during a telehealth call, do not attempt to schedule an appointment or gather routine vitals. Instruct the patient to call 911 immediately.

• Durable Medical Equipment (DME): Must be 1) Durable, 2) Medical, 3) For Home Use.

  • Examples: Wheelchair, Crutches, Nebulizer.
  • Not DME: Bandages, Syringes (disposable).

4. Final Key Takeaways

• CPOE: Solves handwriting errors.
• Telehealth: Chest pain = Call 911.
• DME: Reusable equipment for home (Crutches).
• Schedule II: Zero refills.
• Documentation: If it isn't charted, it wasn't done.