Quia



50 Document Preventative Services for Diego Lupez

Objectives

• Search for a patient record.

• Document preventative services.

Overview

Diego Lupez indicated that his father has a history of coronary artery disease, so Dr. Martin ordered a lipid profile. The results were total cholesterol 189, HDL: 45 and LDL: 185. Document these results in Diego Lupez’s patient record. English is Diego Lupez’s second language.

Competencies

• Coach patients regarding disease prevention, CAAHEP V.P-4c, ABHES 8-h

• Define coaching a patient, CAAHEP V.C-6, ABHES 5-c, 8-h

• Demonstrate respect for individual diversity, CAAHEP V.A-3, ABHES 5-i

• Demonstrate sensitivity to patient rights, CAAHEP X.A-1, ABHES 4-g, 5-h

• Show awareness of a patient’s concerns related to the procedure being performed, CAAHEP I.A-3, ABHES 5-a, 5-h

• Verify eligibility for managed care services, CAAHEP VIII.P-2, ABHES 7-d

Estimated completion time: 25 minutes

Measurable Steps

1. Click on the Find Patient icon (Figure 3-115).

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FIGURE 3-115 Find Patient icon.

2. Using the Patient Search fields, search for Diego Lupez’s patient record.

3. Select the radio button for Diego Lupez and click the Select button. 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.

4. Create a new encounter by clicking Office Visit in the left Info Panel (Figure 3-116).

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FIGURE 3-116 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 James A. Martin, MD from the Provider dropdown.

7. Click the Save button.

8. Select Preventative Services from the Record dropdown menu that is already open.

9. Click the Add button below the Laboratory Testing table (Figure 3-117).

[pic]

FIGURE 3-117 Add button below the Laboratory Testing table.

10. Select Lipid Profile from the Health Recommendation dropdown menu.

11. Use the calendar picker to document the date in the Date Performed field.

180

12. Document “Total Cholesterol: 189, HDL: 45, and LDL: 185” in the Comments field.

13. Click the Save button. The Preventative Services table will display the preventative services for this encounter.

[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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