Week 5 - JustAnswer



Week 5Crystal J. EvansNeehr Perfect Activity: Case Study ReviewOverviewThis activity is intended for the beginning and intermediate EHR student user. This activity is a detailed case study review, or audit, of a chart and its contents. The student will be introduced to documentation in the health record, how the diagnosis is supported through documentation, the patient’s progress, clinical findings, and discharge status. Foundational knowledge and a basic introductory understanding of the contents of an electronic health record, medical terminology and standard terminology is helpful in completing this activity. PrerequisitesCompletion of Neehr Perfect Scavenger Hunts Levels I, II and IIICompletion of Neehr Perfect Activity: Health Information TerminologyStudent instructionsIf you have questions about this activity, please contact your instructor for assistance.Document your answers directly on this document as you complete the activity. When you are finished, save this document and upload it to your Learning Management System (LMS). If you have any questions about submitting your work to your LMS, please contact your instructorScreen displays are provided as a guide and some data (e.g. dates and times) may vary.Additional resourcesUse of additional resources will be necessary to complete this activity:Your textbook(s) ObjectivesApply current knowledge of electronic health records and location of information.Demonstrate the technical skills necessary to access an EHR system.Demonstrate the ability to filter and locate chart contents.Recognize necessary data based on location, date and/or details provided in the record.The activity Log in to the EHR and open the chart of Karen Knealy to complete this activity. List the patient name and SS#: knealy, karen 100-03-0085Is this an inpatient or outpatient chart? Inpatient. She is being admitted to general surgeryWhere is the location of this patient? Orthopedic wardWhat is the patient’s address, employment information and insurance information? If any of this information is not provided, please indicate so. 203 Scott Street Del City Ok 73602. I don’t see employment information but I do see and phone number. The patient doesn’t have any insurance informationList any problem(s) and diagnoses, along with the status of each (acute, chronic, active, inactive). The patient has DJD disease involving both knees and spine. She also has chronic back painList any procedures and surgeries and their corresponding code (i.e. ICD code). Identify the status of each (acute, chronic, active, inactive). M17.0 Bilateral primary osteoarthritis of knee. Chronic back pain M54.5. DJD of spine M47.9List the medication orders and their order details (dose, route and frequency). Highlight and double click on the order to view the Order Details.-Sodium Choride 0.9% inj 1000ml 125 ml/hr for 30 days-Meperidine inj solution 50mg/1ml iv 2qh prn for moderate to severe painPromethazine inj, Soln 20mg/1ml iv q4g prn for nausea-Hydrocodone 10 mg/ACETAMINOHEN 500 MG TAB, TWO TABLETS PO Q4H PRN for mild moderate pain-DIPHENHYDRAMINE INJ,SOLUTIONTION 20 MG/2ML IV Q6H PRN FOR ITCHING.What are the allergies and the reaction, if listed? Patient has no known allergies Are there any Advance Directives? If so, what are they? I see nothing about advance directives List the last set of vital signs, including height, weight, and BMI. A double clicks on the temperature on the Cover Sheet, in the Vitals box, will take you to the history and provide details of the vital signs. Ht: 65 in, weight 195lbs, BMI32.52 t-98.2F, p-76, R16, BP 12/78. The date of the vitals were april 8th at 12pm Go to the Labs tab: list the most recent lab values for HGB (hemoglobin), WBC (white blood cells) and Glucose. HGB was 13.5 on 4/7, WBC was8.3, Glucose 88l Was there a consult ordered? If so, what type of consult, was the consult note completed and by who. I did not see any consult for this patient ordered. Who completed (or authored) the physician or nurses admit note? Who entered the admit note? The physician admit notes were complete and entered by doctor eight. The nurse’s notes by nurse 1 Does the admission note identify each of the problems listed from question #3? Identify which problems are identified in the admission note and which are not. The admission notes do identify the problems of DJD in both knees and the chronic back pain For inpatient charts, there should be a Discharge Summary written by the primary care provider. Who is listed as the physician who dictated the discharge summary? Identify if there is no discharge summary. The patient summary was dictated by physician 8.Submit your workDocument your answers directly on this document as you complete the activity. When you are finished, save this document and upload it to your Learning Management System (LMS). If you have any questions about submitting your work to your LMS, please contact your instructor. ................
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