/depts/,/depts/uwhealth/,/depts/uwhealth/ambulatory-education/,/depts/uwhealth/ambulatory-education/ambulatory-emergency/,/depts/uwhealth/ambulatory-education/ambulatory-emergency/resources/,

/depts/uwhealth/ambulatory-education/ambulatory-emergency/resources/Emergency-Response-Documentation-Working-Document.pdf

201711333

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100

UWHC,UWMF,

Learning and Development,

Departments & Programs,UW Health,Ambulatory Education,Ambulatory Emergency,Resources

Health Link Document: Ambulatory Emergency Response Documentation

Health Link Document: Ambulatory Emergency Response Documentation - Departments & Programs, UW Health, Ambulatory Education, Ambulatory Emergency, Resources


Page 1 — Ambulatory Emergency Response Documentation ©11/27/17 UW Health Information Services – HLEOS


Ambulatory Emergency Response Documentation


To integrate and standardize workflow efforts surrounding medical emergencies in ambulatory clinics,
clinicians will document using an Allied Health/Nurse Visit encounter.
Documenting the Allied Health/Nurse Visit Encounter
1. Create an ambulatory encounter type of Allied Health/Nurse Visit.
A. Click the Amb Enc button on the main toolbar.
B. Select the correct patient and enter the Date, Type (Allied Health/Nurse Visit), Provider (either PCP or
covering provider), and Department.

2. Document Emergency Medical Response as the Chief Complaint.
A. From the Rooming primary activity tab, open the Visit Info.
B. Document “Emergency Medical Response” as the Chief Complaint.

C. Access Notes section from right sidebar.
In-Depth

Page 2 — Ambulatory Emergency Response Documentation ©11/27/17 UW Health Information Services – HLEOS

D. Use SmartPhrase .emergencymedicalresponse , then complete all wildcards and SmartLists within this
SmartPhrase. NOTE: Smart-set Emergency / Crash Cart is available to place orders when indicated.


Tip To maximize your screen view for this Note, choose to move your note to the left pane or a floating window.

Notes floating window view

3. Under the Rooming primary activity tab, document standard rooming tasks.
4. Under the Wrap-Up Primary Activity Tab:
A. Document Visit Diagnoses
B. Complete Charge Capture with code HB-Medical Response HB20967, if applicable.
C. Complete the LOS, if applicable.

5. Sign Visit

Find more on
U-Connect
Search Ambulatory Emergency Response Documentation for complete policy
information and links to eLearnings.