Access Training Materials – Cengage



Module 15: Reviewing Working in the Patient Electronic Medical Record

These tasks require you to admit patients using the EHR schedule, link a note to the patient record, and enter patient vital signs and history.

Please refer to Module 5: Working in the Patient Electronic Medical Record as you complete these tasks.

Task 15-1: Admitting Patients Using the Electronic Medical Record

Today is April 8, 2008. You are working with Dr. Appolo today as a clinical medical assistant. Alex Cordova, a patient of Dr. Appolo, arrives for his annual exam. Once Alex has been brought into the exam room, you will change his appointment status to Admitted.

1. Log on to e-Medsys®.

2. Click on the EHR tab on the top menu bar.

3. Click on the EHR Home Page selection from the drop down menu. This will bring up the EHR home screen.

4. At the right of the screen are the list of providers and a calendar. Scroll down till you find Dr. Appolo’s name and click on it.

5. Type in 4/8/2008 in the date field and press Tab. Notice Dr. Appolo is posted at the top of the screen and his associated appointments are listed below. Alex Cordova should accommodate the 1:00 p.m. time slot. Be sure the Cal and Daily radio buttons are checked.

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Reprinted with permission of TriMed Technologies, Corp.

6. Right click on Alex Cordova’s appointment, follow the Status arrow and admit him to the exam room.

Task 15-2: Linking a New Note to a Patient Appointment

Still working with Alex Cordova’s appointment in the EHR, follow the steps below and create a new patient note.

1. Double click on the appointment and a new screen will appear to create a new patient note as demonstrated by the screenshot below.

2. Notice the Annual Exam for April 8, 2008 appears on the left.

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Reprinted with permission of TriMed Technologies, Corp.

3. Now right click on the ANNUAL EXAM BAR as demonstrated below and click on Add New (Linked) and then Patient Note. This brings up Alex Cordova’s new patient note.

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Reprinted with permission of TriMed Technologies, Corp.

4. Next, use the dropdown menu for the template list and select Multisystem E&M1. Change the date to 04/08/2008 and press Tab. Your screen should match the screenshot below.

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Reprinted with permission of TriMed Technologies, Corp.

5. Next, click on the binoculars to the right of the ICD field. Type V70.0 for the patient’s physical exam and click Search.

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Reprinted with permission of TriMed Technologies, Corp.

6. Click on the V70.0 code that displays below the field. This populates the field with V70.0 (ROUTINE MEDICAL EXAM).

7. In the comment field type, “Here for new patient physical exam.”

8. Click Save and then the X next to the patient note, as indicated in the screenshot below. Then click the Home tab to return to the EHR main menu.

[pic]

Reprinted with permission of TriMed Technologies, Corp.

PUTTING IT ALL TOGETHER

Task 15-3: Linking a New Note to a Patient Appointment

Without step-by-step instructions, this task requires you to admit the patient using the EHR schedule and link a new Note to the patient’s appointment. Save your work for your instructor’s review.

1. Julie Michaels arrives for her appointment on April 10, 2008 at 2:30 p.m. Admit her to the exam room for her appointment with Dr. Vincent Venus.

a. Create a new Patient Note; assign a V70.0 for her diagnosis code.

b. In the Template drop down, indicate MultisystemE&M1.

c. In the comment field of her patient note, type, “Here for new patient physical exam. Additional complaint of shoulder pain following softball game.”

2. Barbara Greene arrives for her appointment on April 15, 2008 at 9:30 a.m. Admit her to the exam room for her appointment with Dr. Vincent Venus.

a. Create a new Patient Note; assign a V70.0 for her diagnosis code.

b. In the Template drop down, indicate MultisystemE&M1.

c. In the comment field of her patient note, type, “Here for new patient physical exam.”

Task 15-4: Entering Patient Vital Signs on a Patient Note

1. Log-in to e-Medsys®.

2. Bring up Alex Cordova’s appointment with Dr. Appolo on the schedule for April 8, 2008. Note the time slot for Alex is highlighted in red to indicate he has been admitted to the exam room.

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Reprinted with permission of TriMed Technologies, Corp.

3. Click on the EHR tab at the top of the screen and click on the EHR Home Page.

4. Be sure Dr. Appolo is the default physician and change the date to the right of the screen to 4/8/2008. Press Tab Compare your work with the following screenshot.

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Reprinted with permission of TriMed Technologies, Corp.

5. Alex’s appointment information is listed at 1:00 p.m. Double click on his appointment to bring up his patient chart.

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Reprinted with permission of TriMed Technologies, Corp.

6. Click on the Notes tab on the left side of the screen.

7. Then click on the Multisystem E&M1 Apr 8 2008 item to the left of the screen. This will bring up Alex’s progress note for that day. Your screen should match the screenshot below.

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Reprinted with permission of TriMed Technologies, Corp.

8. Click on the General tab to bring up the vitals screen. Enter the following information for Alex:

|Height: |72” |

|Weight: |225lbs |

|Sitting BP: |165/100 |

|Pulse |68 |

|Respiration |20 |

|Temperature |98.6 |

9. In the General Appearance tab, type: Well groomed, slightly overweight, Hispanic male.

10. In the Comment field, type: Here for New Patient Physical Exam.

Compare your work to the screenshot below.

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Reprinted with permission of TriMed Technologies, Corp.

11. Click Save and then Home to return to the EHR scheduling menu.

Task 15-5: Entering the Patient, Family, and Social History (PFSH) on a Patient Note

Still working in the EHR component of e-Medsys®, you will add information to the patient note regarding the Patient, Family, and Social History.

1. Ensure Dr. Appolo is the default physician and calendar is set for April 8, 2008, as described previously.

2. Double click on Alex Cordova’s time slot to bring up his patient chart.

3. Click on the Notes tab on the left side of the screen.

4. Click on the Multisystem E&M1 Apr 8 2008 listed on the left as detailed below.

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Reprinted with permission of TriMed Technologies, Corp.

5. Next, click on the PFSH/HPI tab. Your screen should display as the screenshot below.

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Reprinted with permission of TriMed Technologies, Corp.

6. Click on the + sign next to the Social History field. This will bring up a prompt to add a new element to the social history as defined below.

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Reprinted with permission of TriMed Technologies, Corp.

7. In this field type the following and click OK:

“Patient is married with 4 children. He smokes approximately 1 pack of cigarrets per day and drinks about one six-pack of beer on the weekends. No illicit drug use.”

8. In the Previous Medical History field, click the + sign, type the following and click OK:

“Had ORIF performed on the right tibia due to a fracture obtained while playing soccer five years ago.”

9. In the Family History field, click the + sign, enter the following and click OK:

“Mother positive for Type II diabetes and moderate obesity. Father deceased 10 years ago due to myocardial infarction related to hypertension. Younger sister alive and well. Older brother alive and well.”

10. Click Print and print the first page only. Label your work: Task 15-5 and turn it in to your instructor.

11. Click the “Save” tab to save your current work. Click on the “Home” tab to return to the EHR scheduler.

Task 15-6: Entering HPI and Physical Exam on a Patient Note

1. Today is April 21, 2008 and Alex Cordova has arrived for his 2:00 p.m. consultation with Dr. Zues. Using the techniques previously described, admit Alex to the exam room and bring up the EHR schedule and double click on his appointment to create a new patient note for this visit. Your screen should match the screenshot below.

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Reprinted with permission of TriMed Technologies, Corp.

Notice his previous appointment of April 8, 2008 is displayed also.

2. Right click on the highlighted consult Apr 21, 2008 and select Add New (Linked) then chose Patient Note as shown below.

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Reprinted with permission of TriMed Technologies, Corp.

3. Change the Provider to Dr. Zues, alter the date to reflect 04/21/2008 and choose the MultisystemE&M Exam from the template field.

4. In the Comment field, type “Consultation for elevated blood pressure.” Click on the binoculars next to the ICD field, type 401.9 in the Search field and press Enter. Compare your work with the following screenshot.

[pic]

Reprinted with permission of TriMed Technologies, Corp.

5. Click Save.

Task 15-7: Entering Vitals and the Physical Exam

Still working in the current patient note, Dr. Zues instructs you to take the patient’s vitals to verify the previous reading.

1. Click on the General tab and enter the following information:

|Height: |72” |

|Weight: |224 lbs. |

|Sitting BP: |170/100 |

|Pulse: |69 |

|Respiration: |20 |

|Temperature: |98.6 |

2. In the General Appearance field enter: Well groomed, slightly obese, Hispanic male.

3. In the CC field, enter: Here for consultation due to high blood pressure.

Compare your work with the following screenshot.

[pic]

Reprinted with permission of TriMed Technologies, Corp.

4. Click Save.

5. Now click on the PFSH/HPI tab. There are no changes to the patient’s history so scroll down to the History of Present Illness list. Enter the following information in the prescribed fields:

|Location: |(Add new, + sign) Cardiovascular |

|Quality: |Elevated blood pressure |

|Severity: |Moderate |

|Duration: |1 month |

|Modifying Factors: |Moderately obese patient |

6. Compare your work with the below screenshot and click Save.

[pic]

Reprinted with permission of TriMed Technologies, Corp.

Dr. Zues has instructed you to enter the physical exam information in the patient’s note.

7. Click on the Exam tab. Scroll down to the body area of Neck and enter the following next to Exam of Neck: “Jugular vein demonstrates slight distention.”

8. Scroll to the organ system of Cardiovascular. For the listed categories, enter the following information:

|Palpation of Heart: |No abnormalities noted |

|Auscultation of Heart: |Slight murmur detected at mitral valve |

|Examination of Carotid Arteries: | |

| |Normal |

|Pedal pulses: |Comparatively weak on left extremity |

| Abdominal Aorta: |No defects or abnormalities noted |

| Femoral Arteries: |Within normal limits |

| Extremities for Edema and or Varicosities: |No edema detected |

|Gastrointestinal (Abdomen) |No hepatomegaly or splenomegaly noted. |

9. Scroll down to the body area of Gastrointestinal (Abdomen) and enter the following next to Exam of Abdomen: “No hepatomegaly or splenomegaly noted”

10. Click Save.

Click Print and label your work as Task 15-7 and turn it in to your instructor.

PUTTING IT ALL TOGETHER

Task 15-8: Entering Vital Signs and PFSH on a Patient Note

1. Enter the vital signs and PFSH components as detailed below for Barbara Greene. When you have finished entering the information in the patient’s record, print your work and label it Task 15-8A.

|Height: |67” |

|Weight: |164 |

|Temperature: |98.6 |

|Pulse: |62 |

|Respiration: |18 |

|Sitting B/P: |120/84 |

|Social History: |Patient is a married Caucasian female, para 3/gravida 3. Denies tobacco |

| |or drug use. Occasionally drinks alcohol. |

|Previous Medical History: |Patient history positive for three C-sections and appendectomy. |

|Family History: |Both mother and father alive and well, ages 70 and 71 respectively. |

| |Mother had breast cancer 15 years ago, mastectomy performed, now in |

| |remission. Two sisters and one brother alive and well. |

2. Enter the vital signs and PFSH components as detailed below for Julie Michaels. When you have finished entering the information in the patient’s record, print your work and label it Task 15-8B.

|Height: |65” |

|Weight: |128 |

|Temperature: |98.4 |

|Pulse: |61 |

|Respiration: |17 |

|Sitting B/P: |118/80 |

|Social History: |Patient is a single Caucasian female with no children. Lives alone, |

| |denies tobacco or drug use. Occasionally drinks alcohol. |

|Previous Medical History: |Patient had voluntary tubal ligation 15 years ago. Had polypectomy 5 |

| |years ago on left sided inferior nasal turbinate. |

|Family History: |Both mother and father alive and well, ages 62 and 64 respectively. |

| |Older sister alive and well. No active diseases. |

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