Patient Intake Procedures

CHAPTER
© 2012 The McGraw-Hill Companies, Inc. All rights
reserved.McGraw-Hill
6
Office Visit: Patient
Intake
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
Learning Outcomes
When you finish this chapter, you will be able to:
6.1 Identify the four stages of patient flow.
6.2 Discuss the main sections of the patient chart.
6.3 Describe the procedures for recording a patient’s
past medical, family, and social history.
6.4 Explain how allergies and intolerances are entered
in the patient chart.
6.5 Describe the procedure used to enter patient

medications.
6.6 Explain how the chief complaint is recorded in a
progress note.
6-2
Learning Outcomes (Continued)
6.7 Explain how a patient’s vital signs are recorded in
the patient chart.
6.8 Explain the uses of an intra-office messaging system
in an EHR.
6.9 Describe how letters are created in an EHR.
6-3
Key Terms
• family history (FH)

• history of present illness
(HPI)
• past, family, and social
history (PFSH)
• past medical history
(PMH)
• patient flow
• progress notes
• review of systems (ROS)
• social history (SH)
6-4
6.1 Patient Flow in the Physician Office 6-5
• Patient flow—progression of patients from the
time they enter the office for a visit until they exit
the system by leaving the office after a visit
• A typical patient flow consists of four stages:

– Check-in
– Patient intake
– Examination
– Checkout
6.1 Patient Flow in the Physician Office
(Continued)
6-6
• Progress note—note documenting the care
delivered to a patient, and the medical facts and
clinical thinking relevant to diagnosis and
treatment
• Past, family, and social history (PFSH)—
commonly used abbreviation for past medical,
family, and social history
• Past medical history (PMH)—patient’s history
of medical problems, including chronic
conditions, surgeries, and hospitalizations

(Continued)
6-7
• Family history (FH)—detailed record of medical
events among members of the patient’s family,
including the ages, living status, and diseases of
siblings, children, parents, and grandparents
• Social history (SH)—information about the
patient’s tobacco use, alcohol and drug use,
sexual history, relationship status, and other
significant social facts that may contribute to the
care of the patient
(Continued)
6-8

• History of present illness (HPI)—description of
the course of the present illness, including how
and when the problem began, up to the present
time
• Review of systems (ROS)—inventory of body
systems in which the patient reports signs or
symptoms he or she is currently having or has
had in the past
6.2 The Patient Chart in Medisoft Clinical
Patient Records
6-9
The main sections of the patient chart window in
MCPR include:
– Patient identifying information (at the top and the
bottom of the window)
– Chart folders (similar to paper folders)

– Notes area (used to enter notes about the patient)
6.3 Medical History 6-10
• The medical history section of the patient chart
includes three folders:
– Past Medical History
– Social History
– Family History
• Each history section of the chart consists of a
single note.
• To enter a patient’s history, open a patient’s
chart, and click the appropriate history folder.
– If none exists, it can be created by clicking Yes when
a message appears.
6.3 Medical History (Continued) 6-11

• To enter a patient’s history:
– Open a patient’s chart, and click the appropriate
history folder.
– If no chart exists, it can be created by clicking Yes
when a message appears asking about creating a
new note.
– Click in the body of the note and begin typing.
– Click the OK button to save the note.
6.4 Allergies 6-12
To record and store patient allergies:
– Click the Rx/Medications folder; the Rx/Medications
dialog box is displayed.
– To add a patient’s allergies and intolerances, click the
Allergy button; the Allergy dialog box is displayed.
– Complete the fields and click the OK button to save
the allergy information.

– The information will be added to the list at the top of
the Rx/Medications dialog box.
6.5 Medications 6-13
• There are three tabs in the Rx/Medications
dialog box:
– Current
– Ineffective
– Historical
• To enter patient medications:
– Use the Current tab of the Rx/Medications dialog box.
– Click the New button to record current medications;
the Prescription dialog box will appear.
– Complete the fields in the Prescription dialog box.
6.6 The Chief Complaint 6-14

• In most practices, the chief complaint is entered
as the title of the progress note for the patient’s
visit.
• To create a progress note (chief complaint):
– A patient chart must first be open.
– Click the Note button on the toolbar, or, to open an
existing note, click the Progress Notes folder.
– Enter the title and date as needed, and click the OK
button.
• MCPR allows for the use of shared notes, which
are signed by each contributor.
6.7 Vital Signs 6-15
• Patients’ vital sign measurements are entered in
the Vital Signs folder in the patient chart.
• To record a patient’s vital signs:
– Click the New button; the Vital Signs dialog box is

displayed.
– Select the keypad feature via a drop-down list; then
enter numeric entries by using this keypad or by
typing directly in the field.
– Click the OK button to save the entries.
6.8 Messages 6-16
• Staff members can send intra-office messages
using MCPR.
• Messages can be used to:
– Communicate with staff members
– Set up a reminder system or to-do list
– Send attachments
– Link the reader to the relevant portion of a patient’s
chart
– Send messages ranked by priority

6.9 Letters 6-17
• Letters are sent to patients, other providers,
employers, insurance companies, and others.
• To create a letter in MCPR:
– Click the Letter button on the toolbar, or select Letters
on the Task menu; the Insert Template dialog box will
be displayed.
– Select a template from the list of letter templates and
click the Insert button; the template will be inserted
into the body of the letter.
– Write the letter and click OK to save when done, or
use the Print button.
Unit VI ScholarlyActivity Chapter 10 discusses diffusion of
responsibility—a belief that others will help someone in need,
leading to a lessened sense of individual responsibility and a
lower probability of helping. In this assignment, you will
explore how diffusion of responsibility is exhibited in a real-
world setting. To conduct this demonstration, when you are at
work, on campus, or in some other public situation, act as if you
need help with some minor problem. For example, you can look
around confusedly while looking at your phone or drop

something that will scatter a bit. Choose something innocuous
and harmless to yourself. Do this a couple of times: once when
there are several people present and once when there are only
one or two people around.
After you complete these actions, write down your notes right
away. Using your notes, compose an essay addressing the
following points.
· Describe what you did and how it indicated a need for help to
others.
· b. Explain the behavioral response to the situation when many
people were present and when only a few people were present,
including any differences between the two conditions.
· c. Discuss whether the response you received fit with the
textbook’s discussion of the bystander effect. If your
demonstration did not work out, explain why you think it might
not have.
· d. Describe a behavior that may elicit an aggressive, rather
than a helping, response.
· Discuss whether you think the likelihood of an aggressive
response would differ when many versus few people were
present. Compare this pattern of aggressive responses to helping
responses. e. Draw on research from the textbook or another
resource to support your answers.
Your response should be at least two pages in length. You must
use at least one source as a reference in your paper. All sources
used, including the textbook, must be referenced; paraphrased
and quoted material must have accompanying citations. Please
format your paper and all citations in accordance with APA
guidelines.
CHAPTER
© 2012 The McGraw-Hill Companies, Inc. All rights
reserved.McGraw-Hill

5
Check-in Procedures
Learning Outcomes
5.1 List the six types of information that are gathered as
part of the registration process for new patients.
5.2 Determine which health plan is primary when there
is more than one.
5.3 Describe the purpose of a practice’s financial policy.
5.4 List the types of payments that may be collected
from patients at check-in.
5.5 Discuss the advantages of tracking patients
electronically during a visit.
5-2

5.6 In Medisoft Network Professional, describe the
organization of patient data.
5.7 Discuss how a new patient is added to the database.
5.8 Name the two options used to conduct searches.
5.9 Describe when it is necessary to create a new case
or to utilize an existing case.
5.10 Analyze the information contained in the Personal
and Account tabs.
5.11 Discuss the information recorded in the Policy 1, 2,
3, and Medicaid and Tricare tabs.
5-3
5.12 Describe the information contained in the Diagnosis

and Condition tabs.
5.13 Discuss the purpose of the Miscellaneous,
Multimedia, Comment, and EDI tabs.
5-4
Key Terms
• accept assignment
• advance beneficiary
notice of noncoverage
(ABN)
• assignment of benefits
• birthday rule
• capitated plan
• case
• chart
• chart number
5-5

• coordination of benefits
(COB)
• financial policy
• guarantor
• patient information form
• patient tracking features
• primary insurance plan
• record of treatment and
progress
• referring provider
Key Terms (Continued)
• registration
• secondary insurance
plan
• sponsor
5-6

5.1 Patient Registration 5-7
• Registration—process of gathering personal
and insurance information about a patient before
an encounter with a provider
• If the patient is new to the practice, these six
types of information are gathered:
1. Medical history
2. Detailed patient and insurance information
3. Identification verification
4. Financial agreement and authorization for treatment
5. Assignment of benefits statement
6. Acknowledgment of Receipt of Notice of Privacy
Practices
5.1 Patient Registration (Continued) 5-8

• Patient information form—form that includes a
patient’s personal, employment, and insurance
data needed to complete a health care claim
(also known as a registration form)
• Guarantor—person who is the insurance
policyholder for a patient of the practice
• Assignment of benefits—authorization by a
policyholder that allows a health plan to pay
benefits directly to a provider
5.1 Patient Registration (Continued) 5-9
• Accept assignment—participating physician’s
agreement to accept the allowed charge as
payment in full
• Advance beneficiary notice of noncoverage
(ABN)—Medicare form used to inform a patient
that a service to be provided is not likely to be

reimbursed by Medicare
5.2 Other Insurance Plans: Coordination
of Benefits
5-10
• Primary insurance plan—health plan that pays
benefits first when a patient is covered by more
than one plan
• Secondary insurance plan—health plan that
pays benefits after the primary plan pays when a
patient is covered by more than one plan
• Coordination of benefits (COB)—clause in an
insurance policy that explains how the policy will
pay if more than one insurance policy applies to
the claim
5.2 Other Insurance Plans: Coordination

of Benefits (Continued)
5-11
• Birthday rule—guideline that determines which
of the two parents with medical coverage has
the primary insurance for a child
5.3 Financial Policy of the Practice 5-12
Financial policy—practice’s rules governing
payment for medical services from patients
– New patients are given information about the
practice’s financial policy so they understand that they
are responsible for payment of charges that are not
paid by their health plan.
– Established patients are reminded of their financial
obligations.

5.4 Estimating and Collecting Payment 5-13
• Patient payments are estimated and collected at
check-in.
• Payments collected at check-in include:
– copayments,
– outstanding balances, and
– partial payments.
5.5 Patient Tracking 5-14
Patient tracking features—function attached to
the electronic scheduler that is used during a
patient encounter to track where the patient is
during the different steps of the encounter
– allows any member of a medical administrative team
to see a patient’s whereabouts at a glance
– in some programs, offers the creating of reports

5.6 Patient Information in Medisoft
Network Professional
5-15
• The Patient List dialog box lists all patients,
guarantors, and cases currently in the database.
– Left side of the window displays information about
patients.
– Right side of the window contains information about
cases.
– Patient and Case radio buttons activate their
respective sides.
• Case—grouping of transactions for visits to a
physician office organized around a specific
medical condition
5.7 Entering New Patient Information 5-16
• To add a new patient in MNP:

– Click the New Patient button; the Patient/Guarantor
dialog box opens.
– Enter information from the patient information form.
– Complete the three tabs: the Name, Address tab; the
Other Information tab; and the Payment Plan tab.
• Chart number—unique alphanumeric code that
identifies a patient
5.8 Searching for and Updating Patient
Information
5-17
• To update patient information, select the
Patients/Guarantors and Cases option from the
Lists menu.
• The program offers two options for conducting
searches:
– Search for and Field boxes

– Locate buttons
5.9 Navigating Cases in Medisoft
Network Professional
5-18
• Transactions are usually grouped into cases
based on the medical condition for which the
patient seeks treatment.
– Patients with chronic conditions often have many
transactions in a single case.
– Patients may require more than one case per office
visit if treatment is provided for two or more unrelated
conditions.
– When a patient is treated under workers’
compensation insurance, a new case must be
created.

5.9 Navigating Cases in Medisoft
Network Professional (Continued)
5-19
• Chart—folder than contains all records
pertaining to a patient
• Record of treatment and progress—
physician’s notes about a patient’s condition and
diagnosis
5.10 Entering Patient and Account
Information
5-20
• Personal tab—contains basic information about
a patient and his or her employment
• Account tab—includes information on a
patient’s assigned provider, referring provider,
and referral source
• Referring provider—physician who refers the

patient to another physician for treatment
5.11 Entering Insurance Information 5-21
• Policy 1 tab—used to record information about a
patient’s primary insurance carrier
– Claims are sent to the primary insurance carrier first.
– Capitated plan—insurance plan in which
prepayments made to a physician cover the
physician’s services to a plan member for a specified
period of time
patient’s secondary insurance carrier
patient’s tertiary insurance carrier
5.11 Entering Insurance Information

(Continued)
5-22
• Medicare and Tricare tab—used to enter
additional information about Medicaid or
TRICARE for patients covered by government
programs
• Sponsor—in TRICARE, the active-duty service
member
5.12 Entering Health Information 5-23
• Diagnosis tab—contains a patient’s diagnosis,
information about allergies, and electronic media
claim (EDI) notes
• Condition tab—stores data about a patient’s
illness, accident, disability, and hospitalization
– Information is used by insurance carriers to process
claims.

5.13 Entering Other Information 5-24
• Miscellaneous tab—records a variety of
miscellaneous information about the patient and
his or her treatment
• Multimedia tab—used to save a multimedia file
• Comment tab—used to enter case notes
• EDI tab—used to enter information for electronic
claims specific to this case

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