Registration Visit Tab

The Visit tab displays a variety of visit-specific information and allows the user to update visit, arrival, accident and some patient information. At the bottom of the tab, read-only information displays for the visit’s Admit Date, Discharge Date, and Room/Bed.

Its child tabs allow the user to manage notes, diagnoses, procedures, physicians, additional facility-defined information, and referral information.

To update visit information, follow these steps:

1. Adm Source – Click the dropdown and select who or what entity (admissions source) is sending the patient to be admitted for the visit.
2. Admit Type – Click the dropdown and select the inpatient or outpatient admission type for the visit. If an inpatient type is selected, an inpatient option must be selected in the Patient Type dropdown, and an outpatient option must be selected for an outpatient type.
3. Service – Click the dropdown and select the service being performed during the visit. The service helps determine how the visit is charged if the patient is placed in a room/bed.
4. Patient Type – Click the dropdown and select the patient type for the visit. The type must correspond with the Admit Type and is used to classify patients for room charging, the general ledger, and reporting.
5. Location – Displays the location where the visit was admitted/preadmitted.
6. Visit No – Displays the visit number.
7. OP Location – Enabled for outpatient visits. Click the drop-down and select a servicing location.
8. Serv Dept – Click the dropdown and select a hospital servicing department to associate with the visit.
9. Mode (Arrival) – Click the dropdown and select how the patient arrived at the facility (ambulance, walk-in, etc.).
10. Date (Arrival) – Click the field to enter the date directly or click to select a date from a calendar.
11. Location (Accident) – Enter a generic description in the free-form text field.
12. Date (Accident) – Click the field to enter the date directly or click to select a date from a calendar.
13. State (Accident) – Click the dropdown menu and select a state where the accident happened.
14. Type (Accident) – Click the dropdown menu and select the type of accident (automobile, work related, etc.) that happened.
15. ELOS – Enter the estimated length of stay for the patient, if known.
16. Surgery Date – If the patient is being admitted for surgery, enter the intended surgery date. Click the field to enter the date directly or select a date from a calendar.
17. Menstrual Date – Enter the female patient’s last menstrual date. Click the field to enter the date directly or select a date from a calendar. This is only active for female patients.
18. Height. Enter the patient’s height into either the Ft (feet) and In (inches) fields or the Cm (centimeters) field. The system converts feet and inches to centimeters and vice versa, and then automatically populates the other field.

    Note: If the patient is 1 year old or younger, the Height section displays only In and Cm fields.

19. Weight – Enter the patient’s weight into either the Lbs (pounds) and Oz (ounces) fields or into the Kg (kilograms) field. The system converts pounds and ounces to kilograms/grams and vice versa, and then automatically populates the other field.

    Note: RCM Cloud^® has a height/weight check option that checks for the reasonability of the height and weight entered compared to the patient’s age. If the height/weight entered vary from chart averages, a warning message displays when Save is clicked, helping reduce the chance of errors when entering the information.

20. Isolation – Click the dropdown and select a reason if the patient is in isolation. The isolation type can be tied to orders to promote safety for the staff and patient through enhanced communication.
21. Pregnant – Check to designate the patient as pregnant. This is only active for female patients. If Order Management is being used by the system, Order Conflict Checking can be set up to post warnings when certain items are ordered or scheduled for a pregnant patient.
22. Valuables – Check if the facility is storing valuables for the patient.
23. Using Oxygen – Check if the patient is using oxygen.
24. Click Save.

Notes

The Notes tab lists all user and system-generated notes that are associated with the visit. Note information includes the date, user, code, and narrative. Notes can be sorted by clicking on the column headers. Coded or free-form notes can be added in the tab.

Click the System Notes checkbox to view only system-generated notes.

Add Notes

To add a note, follow these steps:

1. Click the Add button . A row is added to the Notes list with the current date, user adding the note, and the application area (Collections, Billing, Registration, etc.) populated and the Visit Note Information fields enabled.

2. Enter note information using one the following options:
   • Coded note – Enter a note code in the first field or a note description in the autocomplete field (clicking a suggested description to select it).

• • Free-form note – Enter free-form note text into the Narrative field.

The information populates the list.

You can only delete a note prior to saving it. Click the Delete  button. The note is removed.

3. Click Save.

Strikethrough a Note

Although notes cannot be deleted once they have been saved, strikethrough lines can be applied to out-of-date notes. The Strike action is located to the right of the Narrative field for saved notes. The strikethrough option allows notes to be designated as no longer used, helping the user determine which information is current on the medical record. Strikethrough lines can be removed. To strike a note, follow these steps:

• 1. Click Strike in the Action column to the right of the note narrative. A strikethrough line displays over the note’s fields.

• 2. Click Save.
  3. To remove the strikethrough line, click Un-Strike.

Diagnosis

The Diagnosis tab is used to add or delete diagnoses (admitting, final, or secondary) for the visit. The diagnoses indicate what a patient is being treated for and can work in conjunction with Medical Necessity Checking to verify the necessity of certain procedures.

While multiple diagnoses can be added, only one admitting and one final diagnosis are allowed on the visit. Secondary diagnoses have no limit.

Diagnoses can be added to the visit record by using existing diagnosis codes or by entering free-form text. Only admitting and secondary diagnoses can be added via free-form text.

To add a diagnosis, follow these steps:

1. Click the Add  button. A row is added to the list, and the Type dropdown menu defaults to:
   • Admitting – If there are no other diagnosis codes associated with the visit. This is the diagnosis/major complaint when the patient was admitted.
   • Final – If there is an admitting diagnosis code associated with the visit. This is the official diagnosis (if determined to be different from the admitting diagnosis), as determined by the facility’s personnel, and the issue treated.
   • Secondary – If there are admitting and final diagnoses codes associated with the visit. This is a diagnosis that is recorded for tracking but may not be related to the principal diagnosis.

2. Type – Click the drop-down and select a diagnosis type, if needed.
3. POA – Click the drop-down and select an option to identify if the diagnosis was present on admission.
4. Enter the diagnosis by one of the following methods:
   • Diagnosis – Enter a diagnosis code in the first field or a diagnosis description in the autocomplete field (clicking a suggested description to select it).

• • Freeform – Enter free-form text into the field.

5. Click Save.

Delete Diagnoses

To delete a diagnosis, follow these steps:

1. Click on a diagnosis in the list to select it.
2. Click the Delete button . The diagnosis is deleted from the list.
3. Click Save.

Procedure

The Procedure tab is used to add or delete procedure codes for a visit. Procedures can be added as principal or secondary, but a visit can only have one principal procedure. Procedures cannot be updated.

To add a procedure, follow these steps:

1. Click the Add  button. A row is added to the list, and the Procedure Information fields below are enabled. The Type dropdown menu will default to Principal if there are no procedures on the visit and Secondary if there is already a Principal type.

2. Type – Click the dropdown and select a procedure type (principal or secondary).
3. Procedure – Enter a procedure code in the first field or a procedure description in the autocomplete field (clicking a suggested description to select it).
4. Date – This date defaults to the admit date. Click the field to enter the date directly or click to select a date from a calendar.

5. Click Save.

Delete Procedures

To delete a procedure, follow these steps:

1. Click on a procedure in the list to select it.
2. Click the Delete button . The procedure is deleted from the list.
3. Click Save.

Physicians

The Physician tab is used to add or delete physicians (admitting, attending, etc.) to the visit. This provides a history of physicians who have treated the patient during the visit. While multiple physicians can be added, only one Admitting and one Attending physician are allowed on the visit.

To add a physician, follow these steps:

1. Click the Add  button. A row is added to the list, and the Physician Information fields below are enabled.

2. Type – Click the dropdown menu and select a Physician Type (attending, consulting, ordering, etc.).
3. Phys Id – Enter a physician code in the first field or a physician name in the autocomplete field (clicking a suggested description to select it).

4. Click Save.

Delete Physicians

To delete a physician, follow these steps:

1. Click on a physician in the list to select it.
2. Click the Delete button . The physician is deleted from the list.
3. Click Save.

Additional Info

The Addl. Info tab is used to collect facility-defined information that is not captured elsewhere in the system. This information is captured using a variety of data types (text, numbers, dollars, dates, times, drop-down menus, etc.) and is unique to a location. The Patient column indicates whether the data entered is stored at the patient (Yes) or visit (No) level.

To add information to a user-defined field, follow these steps:

1. Click on a field to select it. The field displays in the Additional Information section below the list.

2. Depending on the type of user-defined field, enter the information:
   • Alphanumeric/String. Enter alphanumeric information.

• • Numeric/Integer – Enter a number.

• • Dollar – Enter a dollar amount.

• • Date – Click the field to enter the date directly or click to select a date from a calendar.

• • List – Click the drop-down and select an option from a list.

• • Time – Enter the time or click the calendar icon and select a time.

 

• • Checkbox – Click to check or uncheck the box.

The information displays in the Value column in the list.

3. Click Save.

Update User Defined Fields

To update a user defined field, follow these steps:

1. Click on a user defined field in the list to select it.
2. Make any necessary changes.
3. Click Save.

Referral Information

The Referral Information tab is used to record referral information details, including location-specific referral type and source or referring physician information for the visit. This information can be used for reports to track outside referrals.

To add referral information, follow these steps:

1. Referral Type – Click the drop-down menu and select the location-specific referral type for the visit.
2. Referral Source – Click the drop-down menu and select a referral source based on the type selected for the visit.
3. Referring Physician – If configured based on the referral type, this field may be active and allow the addition of a referring physician. Enter a physician code in the first field or a physician name in the autocomplete field (clicking a suggested description to select it).

Note: If the same referring physician already exists for the visit, only the referral type and source are saved in the Referral Information tab. If the referring physician does not exist, the physician is added.

4. Click Save.