Questions and Answers
What should you do with the original X-rays?
Add a bullet point with 'Original X-rays sent with patient' under the selected diagnosis.
What is the purpose of clicking on 'Advice'?
To access all possible advice options.
When should you use the 'Creating the Plan - Referrals' section?
When referring the patient to any specialized doctor.
What must every referral include?
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What to do if no referral options are listed?
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What are discharge instructions?
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What should you do if no discharge instruction options are available?
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If the provider doesn't want relevant discharge instructions, what should be done?
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What is included in the 'Dispenser Meds for this Dx' section?
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What does clicking the + sign next to a medication name allow?
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What should be done to edit existing sigs for prescriptions?
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How do you create a custom prescription?
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What should be filled in when using custom sigs?
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What is the purpose of the global medication search?
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What do you do after selecting 'Send/Print Rx'?
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What are the prescription transfer options after selecting 'Send/Print Rx'?
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What should you do if the 'E' box for e-prescribing is unavailable?
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What information is needed to search for a pharmacy when e-prescribing?
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How can you add advice or instructions that are not available under the advice tab?
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Where can X-rays and their readings be found?
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X-ray readings must always be entered into Opal.
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What is required before ordering CTs for females aged 14-59?
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What are the two most important things on the chart when ordering a CT?
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List five Trauma CTs.
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List five Medical CTs.
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Who completes the IV contrast order?
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What lab requirements are there for a CT with contrast?
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Where can CT images be found?
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Where can CT readings be found?
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What is the username and password for AVR Teleris?
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Where can ultrasound images be found?
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Where can ultrasound readings be found?
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What website shows the list of CTs and ultrasounds with their reads?
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What should be checked when documenting a procedure performed by the provider?
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For a procedure to be billable, the CPT code symbol must be an orange circle with an exclamation point.
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What is required during Same Day CT Transfers?
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When documenting procedures in the plan, the plan must include __________.
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What must you do after a reduction is performed?
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How can vagal events be prevented from Ear Irrigation/Wax Removal?
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What is indicated for document EKG Interpretations?
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What techniques can be used if direct pressure fails to control epistaxis bleeding?
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Study Notes
X-Rays and Imaging
- X-ray readings must be entered into Opal by providers, with some exceptions allowing PFs to assist.
- CT orders require a confirmed negative pregnancy test for females ages 14-59.
- Key chart components for CT orders include HPI and Exam.
- X-ray and CT images and readings can be found on OpalWeb and AVR Teleris respectively.
CT Procedures
- Five trauma CTs: CT Head w/o, CT Facial/Sinuses complete w/o, CT C-Spine w/o, CT Chest (Thorax) w/, CT Abdomen/Pelvis w/.
- Five medical CTs: CT Head w/o, CT Neck w/, CT Angio-Chest w/, CT Abdomen/Pelvis w/, CT Abdomen/Pelvis w/o.
- TAUC CT techs automatically complete IV contrast orders, requiring a creatinine level check prior to contrast.
Anesthesia and Pain Management
- Anesthesia options include local injections, topical application, and nerve blocks, catering to varying procedural needs.
- Common anesthetics stocked include 1% Lidocaine, 2% Lidocaine, 1% Lidocaine with Epi, 0.5% Sensorcaine, and Ethyl Chloride spray.
- Digital and dental nerve blocks are used for finger/toe and dental pain relief, respectively.
Wound and Abscess Care
- Document procedures such as abscess drainage using specific templates outlining preparation, location, and materials involved.
- Follow-up on abscess checks should include evaluation of tenderness and any active drainage.
- Wounds should always undergo irrigation with saline prior to closure, with appropriate documentation for CPT coding.
EKG and Diagnostic Codes
- EKG interpretations consist of rate, rhythm, intervals, axis, and ST-T changes, which can be documented using the EKG Interpretation procedure.
- Utilization of ICD-10 codes requires following specific steps and employing search filters for accurate diagnosis selections.
Referral and Documentation Protocols
- Ensure that every plan contains at least three advice topics and includes follow-up instructions tailored to patient needs.
- Referrals should be region-specific, with 2-4 options selected based on the TAUC location and the specialist required.
- When documenting procedures like ear wax removal, ensure comprehensive detail to trigger appropriate CPT codes.
General Best Practices
- Always check for verbal consent and inform patients about risks and benefits before procedures.
- Maintain patient safety by monitoring for potential vagal events post-procedures like ear irrigation.
- Use appropriate documentation techniques to capture necessary details for reproducing or billing medical services effectively.### Referral Options
- Access referral options by clicking on "referral options" and selecting the specialty.
- This action generates a list of available referral options pertinent to that specialty.
Discharge Instructions
- Patients receive generic information packets related to their diagnosis upon discharge.
- Previously selected discharge instructions for a diagnosis will be automatically listed.
Handling Discharge Instructions
- If no options are available, access "discharge instructions" to view all possible options.
- To add instructions to the plan, click the box next to the desired instruction.
- In case of difficulty finding relevant instructions, use the "global search" feature in DocuTAP's database.
- As a final option, consult online resources about the diagnosis if instructions remain unavailable.
- Chosen discharge instructions will appear as bullet points under the diagnosis.
No Discharge Instructions
- To indicate no discharge instructions are needed, type "Discharge without instructions” in the notes section.
- Not every diagnosis requires discharge instructions; only the most relevant should be attached.
Prescription Management
- Providers often have preferred medications for specific conditions available in "Dispenser Meds for this Dx."
- Includes both TAUC dispensed medications and others used for the diagnosis.
"My Sigs" Section
- Contains all medications stocked at TAUC along with any additional prescriptions saved by providers in DocuTAP.
Viewing Medication Formulations
- Clicking the + sign next to a medication name displays available formulations for that medication.
Editing Existing Sigs
- Information for selected medication and formulation is shown below the diagnosis.
- To edit an error in dosing or modify a specific element, right-click the medication and select "Edit."
- A new window opens with pre-loaded sig data allowing customizable changes indicated by red arrows.
Creating Custom Sigs
- Access the customization menu by clicking on a medication name; contains options for TAUC formula and standard sigs.
- Customize by selecting formulation, dosage frequency, route, duration, and total quantity.
Global Medication Search
- If a medication is not available at TAUC or in the standard list, use the global lookup function for searching.
- Enter the correct spelling of the medication in the search field to generate results.
- Custom sigs can be created from search results.
Medication Dispensing Options
- After selecting a medication, the prescription will display below the diagnosis.
- "Send/Print Rx" option provides choices for dispensing and prescribing medication.
Prescription Transfer Methods
- The available options after selecting "Send/Print Rx" include:
- E = E-Prescribe
- F = Fax
- P = Print
- D = Dispense at TAUC
Dispensing Medication
- To dispense medication directly, check the "D" box.
E-Prescribing and Faxing
- Access a dedicated menu for searching pharmacies with patient-provided pharmacy name and cross street aiding the process.
Sending Prescriptions When E-Prescribing Is Unavailable
- For controlled medications, print the prescription (attach DEA number) or send it from the provider's PC.
- If a sig is not suitable for electronic submission, select "F" to fax the prescription to the pharmacy.
E-Prescribing Process
- Narrow down pharmacy choices by inputting store name and zip code; cross-street information can assist in finding zip codes.
- Select a pharmacy to send the medication electronically.
- Printing prescriptions is primarily for narcotics that cannot be sent electronically; remember to include the DEA number.
Creating the Plan - Free Text Box
- A "Free Text" box is available at the bottom of the plan screen to enter additional advice or instructions.
- Content typed in this box will appear as a bullet point under the diagnosis after saving.
- Useful for notes related to work and printed scripts.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Description
Test your knowledge with these flashcards from the ScribeU final exam. Each card focuses on key concepts related to X-rays, CTs, and the OpalWeb system. Perfect for anyone preparing for the exam or looking to reinforce their understanding of medical imaging.
