Chart Information/Advice Please

[ms_orion]

Two incidents: 1). A patient enters the clinic and stops at reception. He hands her a note with a list of the medications he needs to have refilled. Receptionist comes to me with note and tells me "I looked in his chart but I didn't see (the meds) listed. 2). A pt stops reception and says he needs another order for the lab as he has misplaced the original order. Receptionist opens the electronic medical record, clicks his last chart note and then calls me over. "Mr X needs a new lab order but I dont see where the Physician ordered any tests on his last visit"!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!WHAT IS THE RECEPTIONIST DOING IN THE MEDICAL RECORD.....she does not have the authority to call in refills, and she does not have the authority to write the lab order/diagnosis. Is she supposed to be looking in the pt medical record? Is that common? Please advise me.

[ArmyMSN]

Our Army receptionist peform Telephone Consults - patients make requests - ie medication refills, and the receptionists place the request in a computer program with the requests - its up to the MD to fill the request. I guess the same could be said for a lab request. -

[anticoagulationurse]

We encourage the receptionist to look in the chart for relevant info the patient is requesting. There is no need to involve a DR or nurse for a simple request such as taking a message that such and such med is needed, and then verifying the med is in use. We use an EMR and the receptionist taking phone calls treats a walk in patient the same as they would a call. Gather as much info as possible, attempt to clarify simple things. And yes, on occasion, the nurse or physician will leave a message in the EMR which the receptionist can relay to the patient. THey are not using judgment or advise, just relaying info from one side to the other, which HOPEFULLY saves the nurses and docs some time, if the info is gathered appropriately.

I agree, a nurse should be the one to provide the orders (with approval of MD, of course) for meds or labs to the patient, but if it has already been ordered and someone just needs to let patient know, what's the big deal? Just depends, on the specifics of what your receptionist was trying to accomplish.