Vista Simulation Checking Out a Patient - Amazon S3



Data RetrievalName: Samantha Muncy What is the Access Code? Him1What is the Verify Code? Him1What is the Name of the Patient? Seventy, patientWhat is the Patient’s Phone Number? 222-555-8235List the Patient’s Primary Eligibility. Sc less than 50%Has the Patient’s Insurance Eligibility been verified? noDoes the patient have any future appointments scheduled? noneList all active problem for this patient. Hypertension, hyperlipidemia, acute myocardial infarction, chronic systolic heart failure, and diabetes Miletus type 2List all thing this patient is allergic to. penicillin and chocolateWhat medication is the patient currently taking? 81 mg aspirinWhat is the patient’s Fahrenheit temperature? 98.5List the month, date, and year this patient’s Advance Directive was signed. May 17, 2007Who was the author of the Advance Directive note? Labtech, fifty-nineHow many active problems are listed for this patient? 5What is the status of this condition? chronicWhich provider changed the PRIORITY status from Unspecified to Chronic? Vehu, seventyWhat is the dosage (in mg) of Simvastatin prescribed to this patient? 40What is the status of the Potassium Blood Serum 14981 lab? pendingOn this date, this patient was seen for a hearing aid fitting and what else? orientationWhen did this patient’ cardiology consultation take place? 5/21/2007What is the provisional diagnosis for this patient’s cardiology consultation? irregular pulseAccording to the Operation Report, was this hernia repair surgery with or without mesh? With meshWhat is the FOURTH Discharge Diagnosis listed for this patient? hypertensionAccording to the D/C Summary, where is this patient being discharged to? homeUpon discharge, what is this patient’ condition? goodWhere will this patient seek follow-up treatment? Cardiology clinicAccording to the D/C Summary, this patient should follow-up with which provider? Primary care providerWhat is the HDL lab value for this patient? 58According to the Reference Range, is this value normal, high, or low? normalWhat is the first medication on the list for Pharmacy All Outpatient Medications? metforminWhat is the RX# of the first medication after sorting the list by Drug Name heading? 500352What is the first medication on the list after sorting the list by Status heading? simvastatinWhat is the beginning date? 02/27/2010What is the ending date? 202/28/2011Under the Clinical Reports Surgery Reports, how many operations are listed for this patient? 1What was the date of that operation? 02/02/2007 What is the Surgical Specialty listed on this patient’s report? generalVista Simulation Scheduling an AppointmentName: Samantha Muncy Fill in the information that you are instructed to type after each prompt.What is the Access code? clerk1 What is the Verify code? Clerk1 Selection Appointment Menu Option: am What does it stand for? Appointment management Select Patient name or Clinic name: primary care clinic 6. OK? yes Why? Those were the directions Select Beginning Date: APR 21, 20xx// today Select Ending Date: TODAY// may-13-20xx Select Action: Quit// ma What does it stand for? Make appointment What is the Patient’s Last Name? BCMA What is the Patient’s First Name? eighty patients Choose 1-5: 3 Appointment Type: Regular// yes regular app Display Pending Appointments: Yes//no Is this a ‘Next Available’ Appointment Request? No next available appointments Enter the Date Desired for this Appointment: 5-12-xx@9:00 Length of Appointment (In Minutes): 60//30 minutesThis Appointment is marked as ‘Not Next Available’, is this Correct? Yes//yes Want Patient Notified of Lab, X-Ray, or EKG Stops? No//no Want Previous X-Ray Results Sent to Clinic? No//no Vista Simulation Checking in a PatientName: Samantha Muncy What is the Access code? Clerk1What is the Verify code? Clerk1Selection Appointment Menu opt: CKWhat does it stand for? Check-in/check-outSelect Appointment Check in or Check Out: (CI/CO): check inAppointment Date: Today//today Select Clinic: Primary Care// primary care What is the Patient’s Last Name? BCMAWhat is the Patient’s First Name? eighty-patientChoose 1-5: 3Continue? yes Vista Simulation Coding an Office VisitName: Samantha Muncy What is the Access code? Doctor1What is the Verify code? Doctor1What is the Patient’s Name? ninety, patient Why are Progress notes written? report the date location duration of services provided What tab do you need to click to create a progress note? notesWhat button do you need to click? New note What Dialog Box appears? Location for current activities What do you need to select for Visit Location? diabetic What is the automatic date of the encounter/visit? now What do you need to type for Progress Note Title? diabetes What two items automatically populate on the Progress Note Properties Dialog Box? The date and time and the providerWhat is the Progress Note Subject Type? Office visit note What are the two styles progress notes can be written in? narrative or SOAP style What does SOAP stand for? Subjective, objective, assessment, and plan What style is used for the progress note? SOAP What do you need to type for S? 76-year old patient presents for follow-up on her diabetes What do you need to type for O? Blood glucose reading normal What do you need to type for A? Diabetes mellitus controlled with current medication. What do you need to type for P? Schedule follow-up appointment in 5 weeksWhat button do you need to click after you review the note? Encounter button What tab do you need to click first to fill-out the Encounter form? Diagnosis tabWhat do the Diagnoses under the Section Name correspond with? Patients problem listWhat two diagnoses/codes did you select? Diabetes mellitus type 1 250.01 and hyperlipidemia 272.4What do you need to click to add additional diagnoses not listed in the Section Name? other diagnosisWhat do you need to type in the Search for Diagnoses box? headacheWhat diagnosis/code do you need to pick from Select from one of the following items? Headache icd-9-cm 784.0Why don’t you need to select a Visit Type? Patient was registered as an outpatient office visitOn the Exams tab, what button do you need to click? Other examsOn the Other Examinations dialog box, what do you need to type? Diabetic examWhat needs to be opened to see the Diagnoses codes on the Encounter form? Clinical reportWhat is the question on the Primary Encounter Provider dialog box? are you provider five, the primary provider for this encounterWhat tab do you need to select to review the diagnoses and procedures? reportsWho reviews the medical record and encounter form after the physician has completed it? HIM coding staffWhat does a coder do if there are discrepancies? Query the physicianVista Simulation Creating an Office NoteName: Samantha Muncy What is the Access code? Doctor1What is the Verify code? Doctor1What is the Patient’s Name? ninety, patientWhat tab do you need to select? notesHow many signed notes are there? 5How many notes are listed? 5What is the date of the first note listed in the Last 100 Signed Notes? May 17, 2007What do you need to select to change the display of the notes? viewWhat do you need to select from the drop-down box? Custom viewWhat dialog box appears? List selected documents dialogue boxWhat does this box do? Allows you to customize the displayWhat are the two ways you can display notes? Chronological or reverse chronologicalWhat are the 11 Display Options? What do you need to select under the Note Tree View? chronologicalWhat is the date of the first note? March 27, 2001What do you need to select from the toolbar? New tabWhat do you need to select from the drop-down box? Custom viewWhat do you need to change the Max Number of Return to? 4What do you need to select under the Note Tree View? Reverse chronological order.How many notes are displayed in this view? 4 What is the date of the last note displayed in this view? March 31 2004. What dialog box opens when you click New Note? Location for current activities What does a note have to be linked to? An appointment, visit, or hospital admissionWhat, where, and when is this note for? Audiology, January 15, 2013 at 17:26 nowWhere is the Visit Location? audiologyWhat dialog box appears next? Progress note propertiesWhat do you need to type in the Progress Note Title? Attending noteWhat is the automatic default for the Date/Time of Note? Current date and time What does the Author automatically default to? The providerWhat is the note listed under on the left side of the screen? New note in progressWhat do you need to type in the Input box? Mr. ninety is a diabetic patient What box do you need to click? reminders What do you need to select from the list? Diabetes-retinal exam What dialog box appears? A reminder- resolution-diabetes examWhat do you need to select on the Reminder Resolution screen? Outside eye exam resultsWhat do you need to select under Outside Eye Exam Results? No information What do you need to select to close this screen? Finish button Where is the reminder placed? Directly in to the note What do you need to select from list that opens when you right-click within the body of the note? Save without signature Why do you select this option? The physician may want to review the note again and sign off later and time Vista Simulation Creating a Problem ListName: Samantha Muncy What is the Access Code? doctor1 What is the Verify Code? doctor1 What will you do in this exercise? Review the functionality of the problem list, add a problem to the problem list, edit the status of a problem, or place an annotation to an existing problemWhat is the Name of the Patient? Ninety, patient What is Tab do you need to select? Problems tab What is listed under View Options? Active, inactive, both active and inactive, removed What View Options is open? Active problemsHow many active problems are listed and what are they? 5, hyperlipidemia, hyper tension, acute myocardial infarction (unspecified site, episode of care unspecified, diabetes Miletus type 1, and chronic systolic heart failure How many inactive problems were found? 0 What active problem do you need to change to inactive? Hyperlipidemia What color is the problem shaded to show it is selected? Blue What letter is listed for the active problem? A What letter is now listed for the inactive problem? IWhat is the default view for the Problem List? Active What dialog box opens when you click New Problem? Problem list lexicon search What do you need to enter under Enter Term to Search? Headache What appears when you click Search? A listing of terms and the corresponding icd-9-cm code What do you need to select from the list and what is the code? Chronic headache icd-9-cm :(784.01) What dialog box opens? Grid dialogue boxWhat do you need to select under Immediacy? chronicWhat do you need to enter for Date of Onset and what automatically populates? TWhat does CPRS automatically associate the problem with? The provider and the clinic visit associated with the encounterWhat do you need to select under Treatment Factors? Service connectedWhat do you need to select to add a comment? Add commentWhat dialog box appears? Annotate a problem dialogue boxWhat new comment do you need to enter? Chronic migrainesVista Simulation Clinical and Health ReportingName: Samantha Muncy What is the Access code? him1 What is the Verify code? him1 What clinical reports will this module allow you to run? Problem list, pharmacy report, health summary report and remote reportsWhat is the Patient’s Name? ninety, patientWhat tab do you need to select? Reports tabWhat category do you need to expand? Clinical reportsHow many Clinical Reports subcategories are there? 11What do you need to click under Available Reports? Generate problem listWhat list do you need to select next? Problem list then all problems listHow many active problems are listed? 5 What does CPRS allow you to run a report on for patients? Current and past medications What report provides flexibility and contains many sorting options? Pharmacy reportWhat do you need to select under Clinical Reports? Pharmacy What do you need to select next? All outpatient How many medications were ordered by Dr. VEHU, ONEHUNDRED? 6 What do you need to click to sort to alphabetical drug name? drug name column headingWhat drug to do need to click? Warfarin What is the MG dosage? 5mgWhat do you need to change the sort to? Last fill date What is the most current (latest) refill date? 2/27/10 What does Meaningful use require? Eligible hospitals and providers to provide patients with access to certain health information within certain timeframesWhat examples are given? Discharge list, problem list, medications, lab results, and allergiesWhat does an Ad Hoc report allow you to do? Select, create and query data you specifyWhat report do you need to select? Health summaryWhat report so you need to select next? Adhoc reportOn the ADHOC Health Summary screen what report do you need to select? clinical reminders maintenance reportOn the Clinical Reminders Maintenance screen what are the four items you need to click? >, diabetes-retinal exam, >diabetes creatine, >diabetes hba1c and >diabetes urinalysis 28. What is the clinical frequency of Diabetes-HBA1C clinical maintenance reminder? Due every 1 year 29.What category do you need to find under Available Reports? Department of defense report 30What do you need to click to run a Clinical Labs report? Lab status 31.What do you need to select under Date Range? All results 32Where does CPRS allow you to retrieve data from? Remote locations 33What do you need to select? Remote labs long view (12yr) 34How many years can you retrieve remote discharge summaries, surgery or procedure information? 12 35Where was clinical data retrieved from? Camp master 36What multiple sites can you run reports from? Hospitals and clinicsVista Simulation Creating a ConsultationName: Samantha Muncy What is the Access code? doctor1 What is the Verify code? doctor1 What is the Patient’s name? Ninety, patient What tab do you need to select? Consults How many consults are listed? 2 In addition to Hematology, which other clinical specialty is listed on the All Consults Report? audiologyWhat can the consult status be? Pending complete scheduled discontinued or cancelledWho can update the consult status? The Requesting or receiving serviceWhat do you need to click to review consult details? view What do you need to select from the View drop-down list? Icon legend What icon title is associated with the Audiology Consult? Consult request Which consult do you need to select? Audiology When was the consult released as an order? 4/2/04 What time was the Audiology Consult completed? 2:27 What consult do you need to select next? Hematology What is the status of the Hematology consult? Dc discontinued Why was the Hematology Consult discontinued? Patient failed to show What do you need to select to enter a comment? action What do you need to select from the drop-down? Consult trackingWhat do you need to type in the Add Comment dialog box? Add commentWhat button do you need to select? New consultWhat dialog box opens? An order a consult dialogue box.What clinical service do you need to select? Audiology outpatientWhat button do you need to click for Provisional Diagnosis? Provisional diagnosis lexicon search buttonWhat box appears? Lookup diagnosis dialogue boxWhat do you need to enter in the Search for Diagnosis field? Hearing lossWhat diagnosis and ICD-9-CM code do you need to select? Hearing loss icd-9-cm 389.9What do you need to enter for the Reason for Request? Hearing lossWhat button do you need to click? acceptWhat button do you need to click to close the unsigned Consult Order? Quit buttonWhat tab do you need to select? ordersWhat color is you UNSIGNED note? blueWhen you right click, what do you need to select from the list? Unsigned note in blue then signWhat dialog box open? Sign order dialogue box.What is the doctor’s signature code? Doctor1Vista Simulation Ordering an Outpatient LabName: Samantha Muncy What is the Access code? doctor1 What is the Verify code? doctor1 What is the name of the Patient? Ninety, patient What tab do you need to select? Orders tabWhat do you need to select under Write Orders? laboratoryWhat dialog box opens? Location for current events What do you need to select under Clinical Appointments/Visits? 1st listing for general medicine What dialog box opens? Order a lab test dialogue boxWhat do you need to type in the Available Lab Tests field? Hemoglobin a1c What are the options for the lab test urgency? Routine stat or asap What is the default urgency for an outpatient? Routine What is the default Collection Type? Send patient to lab What is the default Collection Date/Time? Today For outpatient lab orders, what is the default for How Often? One time What do you need to click to complete the order? Accept order button What must all orders include? An electronic signature What happens when there are unsigned orders? Trigger a notification to the provider What do you need to select from the drop-down menu when you right click the order? signWhat box appears? A sign orders dialogue boxWho can only sign the orders? Doctors and nurse practitioners What is the Electronic Signature Code? doctor1 Vista Simulation Alerts and TriggersName: Samantha Muncy 1.What is the Access code? Doctor1What is the Verify code? doctor1 What five things will you learn? Navigate the cover page and order screens, add patient allergy to the ehr, review a drug file, order medication, review a drug to allergy alert What is the name of the Patient? bcma eighty-nine patientWhat is the first allergy is listed for this patient? strawberriesWhat other allergies does the patient have? Bee stings What are the patient’s signs and symptoms to the strawberry allergy? Itching watery eyesWhat dialog box opens when you click Add New? Causative agent lookup dialogue boxWhat new allergy do you need to add for the patient? Penicillin What is a causative agent? A drug or chemical used to combat diseaseHow many matches for penicillin are found in this search? 190 What is the National Drug File (NDF)? it’s a reference terminology What does a reference terminology contain? A specific set of terms and concepts What do terminologies help form? A common language in an ehr What website is shown? The national library of medicines umls website What does UMLS stand for? Unified medical language system What do you need to type in the search on the website? National drug fileWhat is the NDF? A centrally maintained electronic drug list used by the vha hospitals and clinics.What do Facilities use the NDF for? To check drug interactions, manage orders, send outpatient prescriptions to regional automated mail out pharmacies.What does the NDF include? Clinical drugs drug classes ingredients and national drug codes directory codesAccording to the UMLS website, what US department has authority over generating the NDF drug terminology? Department of veteran affairs veteran health administration According to the UMLS website, how often is the NDF updated? Monthly How many generic drugs are listed for Penicillin under the generic NDF? 2124: After you select Penicillin and click OK, what dialog box opens? Enter allergy or adverse reaction 26. hat do you need to select? Historical27 What are the options on the Nature of Reaction drop-down list? Pharmacological allergy and unknown28: What option do you need to select? Allergy29.What do you need to select for Signs/Symptoms? Hives30.What does the View Orders pane include? Active orders include all pending orders and recent activity31What item do you need to select under Write Orders? Inpatient medication32.What do you need to type on the Medication Order screen? Penicillin33.What do you need to select from the list? Penicillin vk tab34.What is the dosage? 250mg35.What is the schedule? Bid36.What does BID mean? Means two times a day37.What do you need to select under Priority? routineHow does CPRS provide clinical decision support (CDS)? By checking all drug and allergy interaction39.When the penicillin is order, what alert box appears? Order checking40.What does it indicate about the penicillin? Previous adverse reaction41Basic level CDS provides order checking for what two indicators? Drug to drug and drug to allergyBecause the patient is allergic to penicillin what do you need to select? Accept orderWhat reappears? The medication order boxWhat medication do you need to type? doxycyclineWhat do you need to select from the list? Doxycycline oral capWhat is the dosage? 100mgWhat is the schedule? BIDWhat is the priority? routineWhat do you need to select to complete the Medication Order? Accept orderDid a drug-to-drug or drug-to-allergy alert appear? noVista Simulation Ordering a MedicationName: Samantha Muncy What is the Access code? doctor1 What is the Verify code? doctor1What two tabs can a provide order a medication from? Orders and medications tab What tab will you be using? ordersWhat do you need to select from the Write Orders box? Outpatient medication What General Medicine date do you need to select? The one dated august 12 2010 8:00 What dialog box appears? The medication order dialogue box What do you need to type? Iron What do you need to select? Iron (POLYSACC COMPLEX) ORAL, CAP What is the Dosage? 150 MG What is the Route? Oral What is the Schedule? Q Day What is the default Days’ Supply? 30 What is the default Quantity (CAP)? 0 What is the default number of refills? 0 Where should the patient pick up the medication? Window What is the Priority? routineWhat box appears after you click Accept Orders? The order checking dialogue box What is the medication checked against in CPRS? Allergy list and contra dictationsWhat is remote locations check an example of? Health information exchange with in Vista 21: What do unsigned orders trigger? A notification to the provider 22: What dialog box appears when you click Quit? Active order dialogue boxWhat is the order highlighted in and what is the status? Bolded blue and unreleasedWhat do you need to select after you right click on the order? signWhat dialog box appears and for what reason? Order checks dialogue box because only a doctor can sign.What do you need to type in the Electronic Signature Code field? doctor1Vista Simulation Creating a Discharge Summary Name: Samantha Muncy What is the Access code? doctor1 What is the Verify code? doctor1 What is the Patient’s name? ninety, patient What tab do you need to select? Discharge summary D/C summ. What doctor’s discharge summary do you need to select? Ninety, vehuWhat is listed as the patient’s first discharge diagnosis? Same as admn dxesWhat month was the report signed? April Who dictated the report? Vehu ninety What are two ways the discharge summary can be added to the CPRs? From transcription systems or directly from CPRS systemWhen the Discharge summary is uploaded by the HIM Clerk, what must be done and why? It must be reviewed and verified for accuracyWhat does the HIM Clerk need to do if the report is incomplete? Notify the healthcare provider responsible for dictating the reportWhat do you need click to create a Discharge Summary? New summaryHow many templates are there to choose from? 4 Which template do you need to click? Summary <discharge summary>The Dictation Date/Time field automatically populates with what? The current date and timeWhat does a Discharge Summary need to be linked to? A visit and the attending physicianWho is the Author/Dictator of the discharge summary? Resident, newWho is the Attending Physician? Scholar extraordinary What is the Admission Date? March 25, 2004What is not recommended? Copying and pasting informationWhat does a template automatically do? Already assigned templateHow many functions are available to the resident? 14What function do you need to select? Save the report without a signatureWhat dialog box appears? The release document dialogue boxWhat format is the summary in? draft modeWhat happens when you select Yes? Status changes from draft to unsignedWhat needs to happen to make the Discharge summary official and complete? Needs to be cosignedVista Simulation Checking Out a Patient Samantha Muncy What is the Access code? clerk1 What is the Verify code? Clerk1Selection Appointment Menu Option: ck What does it stand for? Check in or check out Select Appointment Check in or Check Out: (CI/CO): Check Out Appointment Date: Today//April 1, 2011 Select Clinic: Primary Care//primary care What is the Patient’s Last Name? bcmaWhat is the Patient’s First Name? Eighty, patient Choose 1-5: type 3 Continue? Yes What information might you need to provide at check-out? Date and time What might you need to select? The provider Vista Simulation Restricted RecordsName: Samantha Muncy What is the Access Code? clerk1 What is the Verify Code? clerk1 What is you access code limited to and on what basis? Your role and a need to know basis What does Role-based security restrict? Restricts access to predefined categories of patients, encounters, or documents based on the users’ needs.What two types of restriction are there? To the chart level or the type of information available In an emergency a user without access can access what type of record? The userWhat is used to determine security breaches and what information can be identified? Audit trails and they identify who when and where the information was accessed and by whomWhat did the patient in this scenario suffer? Massive myocardial infarction What does the physician ask the clerk to check for in the patient’s medical record? An advanced directive What is an Advance Directive? A document that outlines the patient’s wishes when the patient is no longer able to make decisions. Includes such treatment as life support measure and can identify a healthcare representative or person who will make decisions for the patient What is the patient’s name? Ninety, patient What dialog box opens after you select OK? a restricted record dialogue box What is the record protected by? Privacy act of 1974 and insurance portability and accountability act of 1996 What tab do you need to select? Reports tab What do you need to select under Available Reports? Health summary. What do you need to select under Health Summary? Adhoc reportWhat dialog box appears? An adhoc health summary dialogue boxWhat do you need to click from the ADHOC Health Summary? Advanced directive (CD)What box do you need to add it to? Component selection boxDoes the patient have an Advance Directive? noIn this scenario, was it appropriate for the clerk to access a patient’s restricted record to look for an AD? yesWhat does role-based security restrict access to? Predefined categories of patients report and documents based on the users’ need What does the HIPAA Security Rule define Technical Safeguards as? Technologies policies and procedures used to control access of protected health informationAccording to HIPPAA, who must have the ability to control access to e-PHI? A covered entityWho will contact the user that access the restricted record for justification? Security office ................
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