I recently received an email from a rightfully frustrated colleague who complained that they had gone to great effort to schedule a daystay procedure, provided the necessary documentation, and entered an intricate set of orders in advance of the appointed time. In spite of these complete efforts, the orders were lost and had to be done over again late at night and over the phone.
The driving issue that led to this circumstance is related to our so-called "encounter logic". I may have mentioned this in earlier posts, though it deserves repeating. Every time a patient interacts with any part of the health system, a new encounter is created. So if a patient calls the office to make an appointment, a triage encounter is created. When the patient reaches the front desk at the time of that appointment, an office visit encounter is created. When the patient goes to the lab, another; to radiology, another; and so on. When a patient is scheduled for admission, say in the event of an elective procedure, a Preadmit encounter is created. This encounter then changes over to the appropriate admit encounter upon arrival to the facility.
In the case above, a transfusion was scheduled and orders were placed. Unfortunately, those orders were placed on an office visit encounter and not on the Preadmit encounter that is created during the scheduling and registration process. The key is to select the proper encounter in order to place those orders. I realize this might seem onerous (at best), particularly since you are able to review a patient's chart regardless of which encounter is opened. But this is more than data collection; the encounter logic facilitates a variety of tasks including ancillary services, charging and billing and patient location.
The following slide set reviews how to select the correct encounter in the event of a preadmit. This instruction also applies to direct admits and the like.
(Remember to click on the icon at the lower right to open to full screen.)
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