Educational EHR for all healthcare disciplines



Patient Chart Details Submission FormBefore you choose to write a patient chart, it is important to examine the potential educational merits of the chart. Ask yourself the following questions:What Learning Objectives could be met with use of this chart in a homework or skills assignment?Identify core knowledge, physical skills, or important decision-making experiences the student can achieve through the use of this chart.What do you want the student to complete with this patient chart?What do you want the student to think about through this patient chart?What do you expect of the student in relationship to this patient chart?How could the use of this chart enhance a simulation? What Learning Objectives could be met with use of this chart in an interactive simulation setting?What data do you need to provide in the chart for base information about this patient?What skills or assessments should be done with this patient?What unexpected events or common clinical situations could be presented via the use of this patient?Charts can be simple or complex, long or short. All Neehr Perfect EHR patient charts contain some or all of the following types of information. Please provide all patient chart data in the fields below.Patient Chart Data:OVERVIEW & EDUCATIONAL DATAPatient chart summary/synopsis: (Freetext description of the patient scenario.)Suggested uses: (List some ideas for curricular use of this chart. E.g. Particular skills practice, certain type of medication administration, physical examination skills, pathophysiology, etc.)DEMOGRAPHIC DATADemographics/Registration information:Name: Sex: Date of Birth (only month and day are needed): Age:Medical Record Number: Marital Status: Street Address: City: State: Zip: Home Phone: Employment Status: Parent or Guardian Information: Guarantor Information: Insurance: Encounter (i.e. Visit or Admission) Data:Inpatient or Outpatient:Location- choose from:Central ClinicGeneral HospitalShoreline Birth CenterHillside Pediatric HospitalGeneral Hospital ERHighlands Long Term CareValley View Therapy CenterDescription: HEALTH DATAAlerts Data (e.g. Allergies, Fall Risk, Isolation)Type (choose from Advance Directive, Adverse Reaction/Allergy, Crisis Note, or Clinical Warning):Status (choose from Active or Inactive):Subject (May be Free text or marked as NKA):Signs/Symptoms:Notes and/or Attachments (Optional. Attachments can be in gif, jpg or png format only):Problems Data (e.g. active, resolved, chronic or acute problems) Date of onset:Problem (name of problem with ICD code, if applicable):Status (choose from Active, Inactive, Resolved, Removed):Immediacy (choose from Acute, Chronic, Unknown, S/P):Priority (freetext to be used if applicable, e.g. Presenting, Admitting, Primary, etc.):Vitals Data (Include values and times. Repeat as many times as needed.)Date/Time:TPR B/P O2 (include qualifiers, if desired):Pain (types include numerical, CRIES, Nonverbal and Wong Baker):Growth & Development (weight, height/length, head circumference, if applicable):Intake & Output (include method and description, if desired):Orders Tab: (Include all details below. Repeat as many times as needed.)Date/Time:Order Category (Available categories include Scheduled Med, Prescription, Laboratory, Diagnostics, Consults, Procedures, Location, Supplies/Devices, Care, Screening/Measurements, Therapy):Order Item: (This is the name of the medication, lab, diagnostic test, etc. being ordered):Quantity (if applicable):Route (if applicable):Frequency:Order Details (This is a longer text box that can contain freetext description or instructions for order under when applicable):Status (Most often the order status is “Active,” but an order can also be written as “On Hold,” “Flagged,” “Pending,” “Expired,” “Completed,” or “Discontinued”):Meds Tab:Orders of the type “Scheduled Meds” will automatically show up on the Meds Tab. Active Scheduled Meds are the only types of orders that can be administered using the barcoded eMAR.Notes Tab: (Include all details below. Repeat as many times as needed.)Hint: ** Most charts should contain a History & Physical or Admission Assessment and at least one Progress Report to help tell the clinical story.Note Title: (You may choose a title for your note. Common note titles examples are, “Progress Note,” “H&P,” “XRay Report,” “Fall Risk Assessment,” “Teaching Plan,” etc.)Date/Time:Text of Note:Images for note (if applicable):Care Plans Tab: (Care Plans can be partial or complete. They help direct the student and focus their patient care.)Date/Time:Care Plan Title/Nursing Diagnosis:Related Medical Diagnosis:Goal:Interventions & Evaluations:Outcomes:Labs Tab: Date/TimeLabResultsDate/TimeLabResultsABGsABGsPaO2PaO2PaCO2PaCO2pHpHSaO2SaO2HCO3HCO3BMPBMPBUNBUNCO2CO2CreatinineCreatinineGlucoseGlucoseSerum chlorideSerum chlorideSerum potassiumSerum potassiumSerum sodiumSerum sodiumComplete Metabolic PanelComplete Metabolic PanelGlucose, SerumGlucose, SerumBUNBUNCreatinine, SerumCreatinine, SerumBUN/Creatinine RatioBUN/Creatinine RatioeGFR if NonAfrican AmericaneGFR if NonAfrican AmericaneGFR if African AmericaneGFR if African AmericanSodium, SerumSodium, SerumPotassium, SerumPotassium, SerumChloride, SerumChloride, SerumCarbon Dioxide, TotalCarbon Dioxide, TotalCalcium, SerumCalcium, SerumAlbumin, SerumAlbumin, SerumProtein, Total, SerumProtein, Total, SerumA/G RatioA/G RatioGlobulin, TotalGlobulin, TotalAlkaline Phosphatase, SerumAlkaline Phosphatase, SerumALT (SGPT)ALT (SGPT)AST (SGOT)AST (SGOT)Bilirubin, TotalBilirubin, TotalCBC with DifferentialCBC with DifferentialHemoglobinHemoglobinHematocritHematocritRBCsRBCsRDW (RBC distribution width)RDW (RBC distribution width)MCVMCVMCHMCHMCHCMCHCPlatelet countPlatelet countWBCWBCSegmented neutrophilsSegmented neutrophilsBand formsBand formsBasophilsBasophilsEosinophilsEosinophilsLymphocytesLymphocytesMonocytesMonocytesCMP (Comprehensive Metabolic Profile)CMP (Comprehensive Metabolic Profile)AlbuminAlbuminAlkaline phosphataseAlkaline phosphataseALT (alanine aminotransferase)ALT (alanine aminotransferase)AST (aspartate aminotransferase)AST (aspartate aminotransferase)BUN (blood urea nitrogen)BUN (blood urea nitrogen)CalciumCalciumChlorideChlorideCO2 (carbon dioxide)CO2 (carbon dioxide)CreatinineCreatinineGlucose testGlucose testPotassium testPotassium testSodiumSodiumTotal bilirubinTotal bilirubinTotal proteinTotal proteinCreatine kinase (CK) isoenzymesCreatine kinase (CK) isoenzymesCK-BBCK-BBCK-MB (cardiac)CK-MB (cardiac)TroponinCK-MMCreatine phosphokinase (CPK)Creatine phosphokinase (CPK)CreatinineCreatinineElectrolytesElectrolytesCalciumCalciumCalcium, ionizedCalcium, ionizedChlorideChlorideMagnesiumMagnesiumPhosphatePhosphatePotassiumPotassiumSodiumSodiumLipid ProfileLipid ProfileCholesterol, totalCholesterol, totalHDL cholesterolHDL cholesterol LDL cholesterol LDL cholesterolTriglyceridesTriglyceridesLiver Panel (Liver function panel)Liver Panel (Liver function panel)ALTALTASTASTALPALPAlbuminAlbuminTotal proteinTotal proteinBilirubinBilirubinGGTGGTLDLDPTPTUrinalysisUrinalysisColorColorClarity/turbidityClarity/turbiditypHpHSpecific gravitySpecific gravityGlucoseGlucoseKetonesKetonesNitratesNitratesLeukocyte esteraseLeukocyte esteraseBilirubinBilirubinUrobilirubinUrobilirubinBloodBloodProteinProteinWBCsWBCsSquamous epithelial cellsSquamous epithelial cellsCastsCastsCrystalsCrystalsBacteriaBacteriaYeastYeastOther LabsOther Labs ................
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