During my time at Orchard Park, I spent a lot of time on a software program called NetSolutions.  This program is the main computer data-entry software they use.  Some of the activities that I did included:

• Entering demographic information for new admits.

• Updating guarantor and emergency contact information.  I also helping to verify that all patient information was there such as social security number, Medicare # (if applicable), address, and phone numbers.

• Inputting the list of diagnosis ICD-10 codes in ranked order.

• Locating and printing documents to put into the medical record, such as facesheets (the basic patient information sheet that is at the beginning of the record) and the diagnosis list.

• Abstracting patient vitals to add to the physicians' exam list.

I helped put together several physician exam lists while working at my practicum site.  These list the patients that need to be examined when the physicians come to the facility.  For more details on the physician lists, please click the button below.

Abaqis is a Quality Management software program that is accessible online.  The goal of Abaqis is to help healthcare facilities to be ready for surveys by recognizing deficiencies.  When I logged onto the Abaqis website, it listed the patients who have information missing.  They were mainly new admits or recent discharges.  

Some of the questions asked for new admits were:  

• Did the patient come to the facility from a hospital? If so, what hospital?

• Were they diagnosed with heart failure, COPD, acute myocardial infarction, pneumonia, hip replacement or knee replacement?

• What is their method of payment? If insurance, what company?

• Several questions regarding advance directives.

Some questions for discharged patients include:

• Where were they discharged to?

• Do they have Home Health Services?

• Why were they discharged?

• If it was to the hospital, what caused the need for discharge, what shift?

• Did the physician discharge the patient?

In order to locate this information I had to go through each of their medical charts.  I had to check payment information, diagnoses, discharge summaries, and any other document that would lead me to the answers.  After I filled out all of the required information, the patient would be removed from the Abaqis deficiency list.

I consistantly updated the Admission/Discharge Register.  These were manual entries, not in the computer, but in a log book.  I had to write each new (or returning) patient, their record number, payment, date of admission, date of birth, social security number, and contact.  To find some of this information required me to look up the patients in the NetSolutions software.

The Master Patient Index at Orchard Park is kept in small filing drawers.  Every patient that has ever been treated there is filed in alphabetic order.  They use the patient admission sheet (facesheet) and fold it, and tape the bottom, then file them.  I spent some time filing a pile that had built up.  It was a very tight fit.  It won't be long before they will need to upgrade it to allow more patients' information sheets.