The patient is a direct admission.  The provider needs to place admission orders on the chart but the patient is arriving during the night.  You will create a Pre-Inpatient Encounter and then the provider can place the orders during the day before the patient arrives. 

Pre-Register a Patient

In PM Office, double-click Pre-Register Patient to a Bed in the Conversation window. 
 

 
The Person Search window opens.  

Search for the patient using the proper search criteria.  

See the Registration Foundational User Manual for the proper search steps.



The patient is found along with any existing encounters. Now you will create a new encounter for the upcoming visit.

Click Add Encounter at the bottom of the page.


 

The Organization dialog box will display. Enter the 3 letter code for the healthcare facility you wish to search in, then click on the ellipsis button.

 

Select the Facility/Clinic you require then click on OK.

The External MPI search window will appear momentarily and close. 

The Pre-Register Patient to a Bed conversation window opens with the information from the EMPI already populated in the appropriate fields.

Review the fields in the top portion of the screen for completeness and accuracy.

If you are able to complete this pre-registration (either you have the patient in front of you or on the phone), click on the Pre-Reg Status field and select Complete.

 

 

Patient Information Tab

The Tabs (Alerts, Patient Information, Encounter Information, Insurance, Insurance Summary, and Additional Contacts) direct you to screens you will need to fill out. Since this patient has no alerts, the conversation defaults to opening the Patient Information tab.

Fill out the mandatory fields as well as any other fields you are able to:

The Permanent Address should pull from what was entered into the EMPI.

Confirm the address with the patient.

 

Enter a phone type for Preferred Phone from the drop-down.


 

When selected, the corresponding phone number field will become mandatory.

Enter a Phone Number for the patient as well as any other contact details the patient has provided.


 

Enter any other patient details that you have available under Personal Information.

 

Encounter Information Tab

Enter the required Current Encounter Information.

Select an Encounter Type of Pre-Inpatient.


 

Select a Medical Service from the drop-down.


 

Enter a free-text Reason for Visit as provided by the patient or referral documents.


 

Under the Location header, the Facility will pre-populate from the facility selected before you started the conversation. Fill out the Unit/Clinic where the patient will be admitted.


         

When the patient is in front of you or on the phone, try to gather their accommodation preferences.

In the Patient Accom Requested field, enter the type of accommodation the patient has requested. 

Patients expecting/experiencing overnight stays in hospital can indicate or request the type of accommodation they prefer.  

If the patient prefers a standard ward accommodation, it will be provided at no cost as the provincial health plan will cover it.

In cases where the patient has requested and receives a private or semi-private room, the patient accepts responsibility for the daily room charges and signs the Preferred Accommodation forms to indicate that they will agree to pay.

Care providers are not required on a pre-admission, but can be entered if you know them. This will save time when the patient arrives at the facility and their registration needs to be completed.

If you are able to confirm the patient’s Primary Care Giver (PCP) at this point, indicate this in the PCP Verified? field.

Scroll down to the Account Data header to fill in the final required field in the Encounter Information tab.

The Estimated Arrive Date is the date that the patient is scheduled to present for their inpatient visit.

Enter an Estimated Arrive Time if possible.


 

 

Insurance Tab

Insurance information is not mandatory to enter on a pre-registration. If you are able, verify insurance with the patient.

When the patient is not a BC Resident with effective MSP coverage, the Verify Status field will populate with No.

 

When the patient is a resident of another province, enter their Provincial or Territorial health care number as their primary insurance. 

Adult patients are typically their own Guarantor.

In the Relationship to Patient field, select Self from the drop-down.


 

Click on the Search for Health Plan button to open the Health Plan Search window.

In the Search field enter the province the patient is covered under and click the ellipsis button to get the search results.


 

Click to select the appropriate health plan name and then click on the corresponding address in the lower section of the screen.

Click OK to select the plan. You will be returned to the Insurance tab with the selected health plan name filled in.





 

Enter the Health Card/Claim Number from the patient’s card.

An out-of-province health plan will trigger the Out of Province Form Signed? field to become required. Since the patient is not present at the moment, we can’t ask them to sign the Out of Province form.

Enter No in the field.

 

 

Insurance Summary Tab

If any insurance information is entered at the time of pre-registration, it will appear in the Insurance Summary tab in the following order:

Primary Insurance 

Secondary Insurance 

Extended Insurance

Additional Contacts Tab

Additional Contacts are not mandatory to enter on a pre-registration. If you are able, confirm any contact information with the patient and enter it here.

Under Emergency Contact, in the Relationship to Patient drop-down, select the appropriate relationship. Upon doing so, the name fields will become required.

Enter the contact’s First Name and Last Name.

 
 

If the contact lives at the same address as the patient, type s in the Address field, and the Address display will populate with the patient’s address automatically.


 

Enter a Preferred Phone Number for the contact as required



At this point, assume the Emergency Contact is the only contact that we have the information for. You will ask the patient for additional contacts when they present for their appointment.

When you have completed all the tabs, click on Complete.

The Document Selection window will appear.

When you require a Facesheet to be printed, deselect Do Not print documents and deselect Armband Label (by clicking inside the box prefacing the text).

Click on OK, even if you do NOT require any printing, click on OK.  


 
A summary dialog box appears, with the Patient name, Encounter Number and Visit ID.

Click on OK.

The Pre-Register Outpatient Conversation is completed.

 

The patient will be arriving during the night via a direct admission.  You need to place admission orders today in a planned state for the nurse to active when the patient arrives.

Locate the Patient Encounter

Search for your patient. 


 

Enter unique patient identifiers.

Select Enc. Type Pre-Inpatient.

Click OK and the correct patient correct encounter page opens.


 

 

Place Admission Powerplan and Orders in a Planned State

Locate your Quick Orders workflow tab.

Select the appropriate PowerPlan.


   
The Order page opens.

Review the Encounter Type .

Sign the PowerPlan.

The PowerPlan is in a planned state for the Nurse to initiate when the patient arrives.


 

  

The Patient has arrived directly to the unit in the evening and the unit clerk Full Registers the patient.

 

 Fully Register an Inpatient

In PM Office or PowerChart, double-click Register Patient to a Bed in the Conversation window.  This conversation is used to create an Inpatient encounter.


         
The Person Search window will appear.

Search for the patient using the proper search criteria.  

See the Registration Foundational User Manual for the proper search steps.


 

Select the patient then click on the Pre-Inpatient encounter to highlight it, and click OK. The EMPI screen will open briefly and close, and the Register Patient to a Bed conversation window will appear.

 

Patient Information Tab

Start by verifying any information that appears in the demographic header and the Patient Information tab.

With the patient in front of you, ask for their identification documentation and confirm their Name, DOB, Gender, Address, and Phone Number Information, making sure it was pulled forward correctly from the pre-registration.


 

Fill in any personal information as provided by the patient.

 

 Encounter Information Tab

Enter the required Current Encounter information.

The Encounter Type field will be blank.  

Select Inpatient from the drop-down. Upon selecting Inpatient, additional fields will become required.


 

Admit Category, Admit Source, and Arrival by Ambulance are required when creating an Inpatient encounter.

If the Reason for Visit has not been filled out you will need to fill it out now.

 
 

If the patient is coming from another facility the Transferred From field must be filled out.  

This patient is a direct admit, so we do not have to fill these out.

 

 

Enter the proper Source of ID from the drop-down list, based on the ID that the patient provides. If the patient is from out of province, we will select Other Photo ID.


         
The Facility and Unit/Clinic will pre-populate from the pre-registration.

Click on the Bed Availability button to see the status of the beds on the selected unit and select the bed the patient will be occupying.


 

Select an available bed and click OK to assign the patient to it.

You will return to the Encounter Information tab and the selected Room and Bed will be filled out.


 

If the patient is placed in a private or a semi-private room, the Accommodation Reason field must be completed.


 

If not already completed, ask the patient if they have any Preferred Accommodation requests and complete the Patient Accom Requested field.  In the Accom Form Signed field, select an appropriate response.


         
Care providers fields are required on an Inpatient encounter.

Click on the magnifying glass beside a provider search field to bring up the Provider Selection window.

Starting with the Admitting Provider, search by the provider’s last name.


 

Select the appropriate provider from the search results and click OK.

Fill out the Attending Provider for this inpatient visit, and any other care provider information provided by the patient or referral documents.



The Primary Care Provider should be confirmed with the patient at each visit.

Once confirmed, enter Yes in the PCP Verified field.

 If PCP Verified is set to No, the patient will fall onto a Worklist that will prompt staff to connect with the patient during their stay to attempt to verify this information.


 

Scroll down to the Account Data header to review the remaining fields.

The Registration Date and time and Patient Admit Date and Time will be pre-populated.

 

Insurance Tab

Insurance information becomes required on an Inpatient encounter type. The EMPI will automatically check the patient’s MSP Eligibility Status and return a result in the Verify Status field.

If the patient is not MSP eligible, you will need to select a Status in Canada.


 

On each visit, you will need to confirm with the patient whether it is an Accident Related Visit. Select the appropriate response from the drop-down.


 

 

Accident/Injury Information Section

Complete the Initial Accident field as appropriate.

The following initial fields are displayed when Accident Related Visit? = Yes.

 

Field	Notes
Work-Related?	If Yes is selected, another group of fields appears to record the employer information (see below)
Accident Type	Select the best category that describes the accident. Note: depending on the type selected other fields may appear (see below)
Accident Description	Short text description of the accident
Accident Location	Location of the accident. E.g. Home, Burrard and Davie Street, Grouse mountain
Accident Date	Date accident occurred
Accident Time	Time accident occurred

 

 

Work-Related Fields:

These additional fields will appear if Work-Related? = Yes

Field	Notes
Employer Name	Name of the patient’s employer (the one where the accident occurred)
Employer Phone Number	Employer’s phone number (optional)
Employer Extension	Employer’s phone extension (optional)
Employer Email Address	Employer’s main email address (optional)
Employer Address	Employer’s address (optional)

 

 

 

Additional Details:

For some Accident Types, additional details are required. These fields show up if the specified types are selected.

Field	Notes
Sport	If the accident occurred while the patient was participating in a sporting activity then select the type of sport.   Displays for Accident Type: Crush/Blunt, Fall from same level, Near Drowning/Drowning, Off road crash, Other, Other Transport crash, Sprain/Strain/Twist, Stab/Cut/Pierce, Unknown
Role	For accidents involving vehicles – indicates whether patient was the driver or passenger or unknown. Displays for Accident Type: Motor vehicle crash, Motorcycle crash, Pedal cycle crash
Counterpart	For accidents involving vehicles – indicates what the patient’s vehicle crashed into or what the patient was hit by. Displays for Accident Type of: Motor vehicle crash, Motorcycle crash, Off road crash, Pedal cycle crash, Pedestrian struck by vehicle
3rd Party Liability	For Motor Vehicle related accidents, the 3rd Party Liability field, which is usually a hidden field, will display.  It will default to Yes if the following accident types are selected: Displays for Accident Type: Motor vehicle crash, Motorcycle crash, Off road crash, Pedal cycle crash, Pedestrian struck by vehicle

 

Since we entered the Primary Insurance information at pre-registration, it will already be filled out.


         

If the patient provides evidence of extended insurance coverage, enter the details under the Extended Insurance header. 

Click the Relationship to Patient drop-down and select the subscriber’s relationship to the patient.


         
The Last Name and First Name of the subscriber become required. 

Collect and enter any contact information for the plan subscriber as provided by the patient.


 

Click on the Search for Health Plan button to open the Health Plan Search window. In the Search field enter the appropriate plan name and click the ellipsis button to get the search results.


 

Select the appropriate plan name and then click on the associated address in the lower section of the screen.

Click OK to select the plan. You will be returned to the Insurance tab with the selected health plan name filled in.

Enter the Health/Card Claim Number from the subscriber’s card as well as any other information provided.

 

Insurance Summary Tab

Open the Insurance Summary tab to view the health plans that have been entered on this encounter. If there are any comments pertinent to the insurance plans, enter them in the Insurance Summary Comment field.

 

 Additional Contacts Tab

An emergency contact is mandatory for an Inpatient encounter. You may have already entered an emergency contact at the time of pre-registration, but it’s important to gather as much contact information as the patient is able to provide.

 

Under Next of Kin, Select a Relationship to Patient from the drop-down.

If you select a relationship that has been used earlier in the insurance tab, the contact’s information will already be in the system.

The Relationship window will appear and allow you to select the contact rather than entering their information again.


 

Select the contact from the window and click OK.

Their information will display in the appropriate fields.


 

Once all information is filled out to the best of your knowledge, and all required fields are completed, click the Complete button to change the encounter from a pre-inpatient to an inpatient encounter.

The Document Selection window opens.

Print the selected documents by clicking OK.

E.g. armband for the patient, Facesheet for the encounter, and specimen labels as required.

 

The patient has arrived on the unit late in the evening and requires the admission orders to be activated.  The Unit Clerk or after hours the Registration Clerk in Patient Placement can change the encounter from Pre-Inpatient Encounter to an Inpatient; Active encounter.

Review the Encounter type as Inpatient; Active .

Select the PowerPlan from the View pane and review orders.

Click Initiate PowerPlan.