Quia



43 Document Encounter and Schedule Appointment for Walter Biller

Objectives

• Search for a patient record.

• Document medications.

• Document allergies.

• Schedule an appointment.

Overview

It has been two years since Walter Biller’s last appointment with Dr. Walden. His general health needs are met at the clinic where he works, but the nurse recommended he see his primary care physician after he failed to pass a routine eye exam and had glucose in a urine sample. Walter Biller is not currently on any medications, but he says that Darvocet gives him a headache. Dr. Walden diagnoses Walter Biller with Type II DM (without complications), uncontrolled and starts him on Metformin (extended release tablet) 500 mg PO bid. Dr. Walden would like to see Walter Biller again for 30 minutes next Friday. Document Mr. Biller’s encounter and schedule a follow-up appointment.

Competencies

• Display sensitivity when managing appointments, CAAHEP VI.A-1, ABHES 5-h, 7-e

• Document patient care accurately in the medical record, CAAHEP X.P-3, ABHES 4-a

• Maintain medication and immunization records, ABHES 4-a, 4-f

• Manage appointment schedule, using established priorities, CAAHEP VI.P-1, ABHES 7-e

• Properly utilize PDR, drug handbook and other drug reference to identify a drug’s classification, usual dosage, usual side effects, and contraindications, ABHES 6-d

Estimated completion time: 25 minutes

Measurable Steps

1. Click on the Find Patient icon (Figure 3-82).

[pic]

FIGURE 3-82 Find Patient icon.

2. Using the Patient Search fields, search for Walter Biller’s patient record. Once you locate his patient record in the List of Patients, confirm his date of birth.

[pic] Helpful Hint

Confirming date of birth will help to ensure that you have located the correct patient record.

3. Select the radio button for Walter Biller and click the Select button. Confirm the auto-populated details in the Patient Header.

4. Create an encounter for Walter Biller by clicking Office Visit in the left Info Panel (Figure 3-83).

[pic]

FIGURE 3-83 Office Visit in the Info Panel.

5. In the Create New Encounter window, select Follow-Up/Established Visit from the Visit Type dropdown.

6. Select Julie Walden, MD from the Provider dropdown.

7. Click the Save button. Allergies is the first option available within the Record dropdown menu, automatically landing the user in that section of the patient chart.

8. Click the Add Allergy button (Figure 3-84).

[pic]

FIGURE 3-84 Add Allergy button.

9. Select the Medication radio button in the Allergy Type field.

10. Document “Darvocet” in the Allergen field. If Darvocet is not available in the list of allergies, this can be typed in manually.

11. Click the Headache checkbox in the Reactions field.

12. Select Self in the Informant field. Select Very Reliable in the Confidence Level field.

13. Click the Save button in the Add Allergy window. The allergy you added will display in the Allergies grid.

14. Select Problem List from the Record dropdown menu.

15. Click the Add Problem button to add a problem.

16. Select “Diabetes mellitus, Type 2 without complications” from the Diagnosis dropdown menu.

17. Select the ICD-10 radio button and place the cursor in the text box to access the TruCode encoder. Accessing the encoder tool this way will auto-populate any selected codes where the cursor is placed.

18. Enter “Diabetes mellitus, Type 2 without complications” in the Search field and select Diagnosis, ICD-10-CM from the dropdown menu.

19. Click the Search button.

20. Click the code E11.9 to expand this code and confirm that it is the most specific code available.

21. Click the code E11.9 for “Diabetes mellitus, Type 2 without complications” that appears in the tree. This code will auto-populate in the ICD-10 field of the Add Problem window.

22. Document the current date in the Date Identified field.

23. Select the Active radio button in the Status field.

24. Click the Save button. The Problem List table will display the new problem.

25. Select Medications from the Record dropdown menu.

26. Within the Prescription Medications tab, click the Add Medication button (Figure 3-85).

[pic]

FIGURE 3-85 The Add Medication button in the Prescription Medications tab.

27. Document Metformin Extended Release Tablet in the Medication field.

28. Select 500 mg in the Strength dropdown.

29. Select Tablet ER in the Form dropdown.

30. Select Oral in the Route dropdown.

31. Select 2 Times/Day in the Frequency dropdown.

32. Document the indication (Diagnosis) and select the Active radio button in the Status field.

33. Click the Save button in the Add Prescription Medication window. The medication you added will display in the Prescription Medications grid.

34. Click the Calendar icon (Figure 3-86).

[pic]

FIGURE 3-86 Calendar icon.

35. Within the weekly calendar, click on the instructed day to open the New Appointment window.

36. Select the Patient Visit radio button as the Appointment Type.

37. Select Follow-Up/Established Visit from the Visit Type dropdown.

38. Document “Diabetes follow-up” in the Chief Complaint text box.

39. Select the Search Existing Patients radio button.

40. Using the Patient Search fields, search for Walter Biller’s patient record. Once you locate him in the List of Patients, confirm his date of birth.

41. Select the radio button for Walter Biller and click the Select button. Confirm the auto-populated details.

42. Select Julie Walden, MD from the Provider dropdown.

43. Use the calendar picker to confirm or select the appointment day.

44. Select a start and end time for the appointment using the Start Time and End Time dropdowns.

45. Click the Save button. Walter’s appointment will be displayed on the calendar.

[pic] Now use the Back to Assignment link to complete the Post-Case Quiz found on the Info Panel for this assignment.

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