Patient Assessment and History Workflow

Patient Assessment & History Workflow

This quick guide covers what happens through the nurse or MA's chart-prep workflow before the provider comes in. It covers verifying patient identity, insurance, and consent, rooming the patient, charting vitals, and standard assessments like ECOG and pain, reviewing allergies, medications, and history, and finally handing off to the provider.

Verify Patient

• Clinic Schedule – Locate the patient and click on their name to open the patient’s chart
  • Alternatively, you can search for the patient using the Patient Search Bar at the top of the screen
• Demographics – The patient chart will open to the demographics screen. Here you can confirm patient details such as name, DOB, insurance, providers, and patient indicators.
• Patient Locator — Use the Patient Locator in the patient tile to move the patient throughout the clinic (ex: lobby, lab, exam room, etc.)
• Patient Status – Complete as soon as possible

Patient Assessments

• Assessments page -> Vitals tab
  • New Entry – input vitals for the patient
  • Edit the values or time for previous entries by clicking the date at the top of the column you wish to edit
  • Edit – change values entered for vitals
  • Change Date/Time – change the time for any backdated vitals 
  • View History Log – see who made changes to the patient’s vitals and when 
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• Assessments page -> Assessments/ROS/PE/Toxicities tab
  • Navigate through the remaining tabs on the Assessments page to complete any necessary assessments such as ECOG, ROS, PE, PHQ9, etc.
  • Use the +Add New button on the right hand side to select the desired assessment

Patient History

• Patient History page -> Allergies tab
  • View active and inactive allergies
  • Use New Entry button to add an allergy
  • Use the No Known Allergies checkbox on the right hand side if the patient has no allergies to report

• Patient History page -> Vitals tab
  • Vitals are also available via the Patient History page. This tab provides the same functionality as Vitals in other sections of VieCure, just in a convenient place
• Patient History page - > Medications tab
  • Review, add, and reconcile medications through this tab
  • Surescripts – VieCure integrates with Surescripts to keep all medication reconciliations up to date
  • Use the print icon on the right hand side to print a list of medications to send home with the patient or file as a hard copy.
• Patient History page -> DME, Immunization Hx, Medical Hx, Social Hx, Family Hx, Procedures, Advanced Directives, and CCD History tabs
  • Tab through the remaining sections to verify all patient information
• Verify All – verify all sections that were visited at once by using the Verify All button on the right hand side of the screen
  • Please note: only sections that were clicked into will have an actionable checkbox

Route the Patient

• Patient Tile -> Patient Status indicator
  • Update the patient’s status in the patient tile to alert the provider that the patient is ready for next steps
• If your clinic workflow involves labs, you may need to navigate to the Lab Specimen Collection page to complete the patient’s lab orders.