HCA 417 Electronic Health Record EXPERIENCE IN EHR ONLY

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ELECTRONIC HEALTH RECORDS Understanding and Using Computerized Medical Records

CHAPTER LESSON

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Problem Lists, Results Management, and Trending

CHAPTER SEVEN ONE

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Longitudinal Patient Records to Manage Patients' Health

• Medical offices: electronic health record is longitudinal record encompassing numerous encounters over extended period of time.

• Inpatient records: particular inpatient stay or episode of care.

• Term clinician or provider: represents equally a nurse practitioner or doctor.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Longitudinal Patient Records to Manage Patients' Health

• Providers: – Help monitor and improve patient's health. – Keep track of medications and test results.

• In codified electronic chart, software locates necessary information; organizes it for quick review. – Clinician notes items reviewed, makes

updates to problems, records them in current encounter.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Understanding Problem Lists

• Maintaining a Problem List is a requirement for accreditation by organizations such as Joint Commission (JCAHO). – Used to track acute and chronic conditions

related to care of patient. – Everyone who touches patient knows what

conditions are present.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Understanding Problem Lists

• Problem List (cont.) – Problem-oriented view organizes entries in

patient record by problem. – Provides up-to-date list of diagnoses and

conditions that affect patient's care. – Links data from all encounters, orders, and

prescriptions to respective problem.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Understanding Problem Lists

• Problem List (cont.) – Has onset date, indicates Chronic or Acute,

shows whether or not problem is active. – Wellness conditions based on age and sex of

patient; used in health maintenance and preventative screening programs.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 44: Exploring Patient Management

• Patient Management used to manage patient's problems over time.

• Presents clinical summary view of patient's previous visits.

• In this exercise you are going to start a new encounter but the system will automatically retrieve and display information from previous encounters.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 44: Exploring Patient Management

• Case Study – Juan Garcia, an outpatient who has been

treated, previously, is returning for a follow-up visit.

• Step 1 – Start Student Edition software. – Click Select on Menu bar; click Patient. – In Patient Selection window, locate and click

on Juan Garcia.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 44: Exploring Patient Management

Figure 7-1: Selecting Juan Garcia from the Patient Selection window.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 44: Exploring Patient Management

• Step 2 – Click Select on Menu

bar; click New Encounter.

– Select date May 21, 2012, time 9:00 AM, and reason Office Visit.

– Make certain date and time match before clicking on OK button. Figure 7-2 New encounter for an

office visit, May 21, 2012 9:00 AM.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 44: Exploring Patient Management

• Step 3 – Enter Chief complaint

by locating button in Toolbar labeled “Chief” and clicking on it.

– In dialog window, type “Knee injury follow- up.”

– Click on “Close the note form.”

Figure 7-3: Chief complaint dialog for knee injury follow-up.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 44: Exploring Patient Management

• Step 4 – Locate and click on tab labeled “Manage” at

bottom of screen (circled in red in Figure 7-4). – Compare screen to Figure 7-4. Medcin

Nomenclature normally displayed in left pane of screen has been replaced by information window displaying information from previous encounters.

– When you are on Manage tab, Toolbar has some additional buttons.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 44: Exploring Patient Management

Figure 7-4: Manage tab (circled in red) and Details button (highlighted orange).

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 44: Exploring Patient Management

• Step 4 (cont.) – Locate and click on button in Toolbar labeled

“Details.” – This action allows you to see more of Patient

Management by hiding Entry Details section at bottom of screen.

– Entry Details section can be restored when it is hidden by clicking Details button again.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 44: Exploring Patient Management

• Step 4 (cont.) – Left pane of screen contains nine tabs:  Problem List  Care Plan  Medications  Vaccines  Allergies  Past Medical/Surgical History (Med/Surg)  Family History  Social History  Vitals

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 44: Exploring Patient Management

• Step 5 – Manage tab opens

on Problem List tab (circled in red).

– Problem List includes view of active and inactive problems and nursing assessments.

Figure 7-5: Problem List tab (circled in red) with details hidden.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 44: Exploring Patient Management

• Step 5 (cont.) – Within Problem List are three columns: Tests,

Medications, and Procedures/Other. – If tests ordered, they appear in first column. – Medications prescribed appear in second

column. – Last column lists other orders or procedures

from past encounters related to problem.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 44: Exploring Patient Management

• Step 6 – Click on tab labeled

“Care Plan” – Care Plan tab

displays each problem, followed by date of each encounter that patient was seen for problem. Figure 7-6: Care Plan tab (circled in

red)

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 44: Exploring Patient Management

• Step 6 (cont.) – Small plus signs next to encounter allows you

to expand encounter to display Care Plan for that date.

– Click plus sign beside each encounter date. – Findings from Plan section of encounter note

are displayed beneath encounter date; findings from any group can be manually added to Care Plan.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 44: Exploring Patient Management

• Step 7 – Click on tab labeled

“Medications.” – Medications tab lists

medications ordered by any clinician in the practice as well as those reported by patient.

Figure 7-7: Medications tab (circled in red).

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 44: Exploring Patient Management

• Step 8 – Click on tab labeled

“Vaccines.” – Tab displays patient's

history of vaccines. – (Note that vaccines

also appear in Medications list.)

Figure 7-8: Vaccines tab (circled in red).

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 44: Exploring Patient Management

• Step 9 – Click on tab labeled

“Allergies.” – Tab displays allergy

information from patient encounters.

– In this case, patient reported “No allergies.”

– Providers check both Medications and Allergies tabs before writing a prescription.

Figure 7-9: Allergies tab (circled in red).

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 44: Exploring Patient Management

• Step 10 – Click on tab labeled “Med/Surg.” – Tabs in left pane are arranged in two rows;

when you click any tab in upper row, entire row moves down.

– Tab for data currently displayed in left pane is always in bottom row of tabs closest to grid.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 44: Exploring Patient Management

• Step 10 (cont.) – “Med/Surg” stands for

Medical and Surgical History; displays all findings that have been recorded in Past History section of previous encounters.

– Date column displays date finding was recorded.

Figure 7-10: Past Medical and Surgical History tab.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 44: Exploring Patient Management

• Step 11 – Click on tab labeled

“Family History.” – Tab displays all

findings that have been recorded in Family History section of previous encounters.

– Date column displays date that finding was recorded.

Figure 7-11: Family History tab (circled in red).

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 44: Exploring Patient Management

• Step 12 – Click on tab labeled

“Social History.” – Tab displays all

findings that have been recorded in Social History section of previous encounters.

– Date column displays date that finding was recorded.

Figure 7-12: Social History tab (circled in red).

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 44: Exploring Patient Management

• Step 13 – Click on tab labeled

“Vitals.” – Tab displays Vital

Signs findings that have been recorded in multiple encounters.

Figure 7-13: Vitals Signs tab (circled in red).

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 44: Exploring Patient Management

• Step 14 – In each of the tabs data can be sorted. – Done by clicking on labels over columns of

data. – Locate and click on column labeled “Temp”

within Vitals tab.

Figure 7-14: Vital signs sorted by patient temperature.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 44: Exploring Patient Management

• Step 14 (cont.) – Notice that rows of vital signs data changed

places and date that Juan had temperature of 101°F is now top row.

– When sorting, entire row stays together. – To restore Vitals tab to its original order, click

on column labeled “Date.” – Data in any tab of Patient Management can

be sorted by clicking on column labels.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Citing Previous Visits from Problem Lists

• Patient Management is an excellent tool for reviewing information from patient's previous encounters without having to open and read each one individually.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Citing Previous Visits from Problem Lists

• It is more than just review tool; it is an efficient method of documenting a follow- up exam.

• In EHR, citing from a previous encounter note means to bring a finding into current encounter.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Case Study – Juan Garcia has returned for a follow-up on

his previous knee injury. – Using Patient Management, you will see how

easy it is to document this type of visit.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 1 – If continuing from previous exercise, proceed

to step 4. – Otherwise, start Student Edition software. – From Select Menu, click Patient, and from

Patient Selector window select Juan Garcia.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 2 – From Select Menu, click New Encounter. – Use date May 21, 2012, time 9:00 AM, and

reason Office Visit. – Make certain date and time match before

clicking on OK button (see Figure 7-2).

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 3 – Enter Chief complaint. – Click button in Toolbar labeled “Chief” – In dialog window, type “Knee injury follow-up.” – Click on button labeled “Close the note form.”

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 4 – Enter Juan Garcia's vital signs using Vitals

Form in corresponding fields as follows:  Temperature: 97  Respiration: 17  Pulse: 68  BP: 120/86  Height: 68  Weight: 149

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 4 (cont.) – When you have finished, compare your

screen to Figure 7-15. – If correct, click on tab labeled Manage at

bottom of window. – If you have difficulty locating Manage, refer to

Figure 7-4.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

Figure 7-15: Vital Signs form for Juan Garcia.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 5 – Verify that you are on Manage tab. – If information pane on left of screen is not

displaying Problem List, click on tab labeled “Problem List” (circled in red in Figure 7-5).

– If Entry Details section is covering bottom of screen, locate button labeled “Details” in Toolbar at top of screen and click it until Entry Details section is hidden.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 5 (cont.) – Position mouse pointer over first problem,

“Sprained anterior cruciate ligament of the knee;” click Right button on mouse.

– Drop-down list displayed (Figure 7-16). – If drop-down list does not match list shown in

Figure 7-16, your mouse was not positioned correctly on problem description.

– Reposition mouse; click Right mouse button again.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

Figure 7-16: Problem List tab with drop-down list from right click of mouse.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 5 (cont.) • Explanation of Options in Drop-down List

– Edit Problem Note: Allows you to edit free-text note that is attached to problem.

– To record status of problem  Expanding  Failing to Change as Expected  Improving  Inadequately Controlled

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 5 (cont.) • Explanation of Options in Drop-down List

– To record status of problem  Mildly Exacerbated  Resolved  Resolving  Severely Exacerbated  Unchanged  Well Controlled  Worsening

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 5 (cont.) – Clear This Problem: Clears all test orders,

discontinues medications related to problem, clears therapy orders, sets problem as inactive.

– Quick H&P: Invokes data entry window that lists symptoms, history, and physical findings as they appeared in most recent encounter for problem.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 5 (cont.) – Order a Test: Allows clinician to order new

test for problem. – Order a Medication: Allows clinician to order

new medication for problem. – Order a Therapy: Allows clinician to order any

type of therapy other than medications. – Ignore Action: Cancels drop-down list without

recording anything.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 6 – Locate and click on Quick H&P option in drop-

down list (highlighted in Figure 7-16). – Quick History and Physical window invoked. – Compare your screen to Figure 7-17. – Window displays findings from previous exam

for this condition. – Items that have been entered in today's

encounter appear on Quick H&P list in gray.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

Figure 7-17: Quick history and physical for knee injury.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 6 (cont.) – Patient reports that his knee is better. – Locate and click on following findings (you will

need to scroll window to get them all):  Left knee joint pain (blue button)  Left knee joint swelling (blue button)  Taking antibiotics (blue button)

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 6 (cont.) – Locate and click on following findings (cont'd)  Localized swelling of the left knee (blue button)  Warmth of the left knee (blue button)  Pain was elicited by motion of the left knee (blue

button) – Important: do not click every finding that is

listed. Click only those indicated above.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 7 – Compare your screen to Figure 7-18. – Scroll window and verify that you have

selected only items listed in step 6. – If you find an error, click on button labeled

“Cancel,” and repeat steps 5 and 6. – When all findings have been selected

correctly, click on button labeled “Post To Encounter.”

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

Figure 7-18: Knee injury findings set to normal, ready to post to encounter.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 8 – Findings you selected in Quick H&P window

should be displayed in patient encounter note. – Problem is resolved. To indicate this in

today's encounter note, position mouse over first problem, “Sprained anterior cruciate ligament of the right knee;” click Right button on your mouse.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 8 (cont.) – Again drop-down list

will be displayed – Locate and click on

option labeled “Resolved.”

– Window shown in Figure 7-20 will be invoked.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

Figure 7-20: Resolving a problem—Action Confirmation List.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 9 – When a problem is resolved:  Cancel previous orders  Discontinue any medication  Set problem as inactive

– Resolved option invokes window of all active orders related to problem and sets appropriate default actions.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 9 (cont.) – Check box next to each item indicates action. – Drop-down list of actions is available for each

order (Figure 7-20). – Use list to select different action or indicate no

action is to be taken by unchecking box. – Do not make any changes to default list. – When list reviewed, locate and click button

labeled “Take All Actions That Are Checked.”

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 10 – Knee problem in left pane has moved to

section labeled “Inactive Problems.” – If not displayed, locate and click small plus

sign next to “Inactive Problems.” – Compare your screen with Figure 7-21. – Note in right pane that previous therapy

orders have been canceled.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

Figure 7-21: Inactive problem on Problem List.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 11 – Problem List also listed a second problem,

acute sinusitis, for which patient was recently treated.

– Patient reports that sinusitis has cleared up and that he has finished prescribed course of antibiotics.

– Using what you have learned in previous steps, resolve acute sinusitis problem.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 11 (cont.) – Position mouse pointer on active problem,

“Acute sinusitis.” – Click Right button on mouse and select

Resolved from options on drop-down list. – Action confirmation list window (Figure 7-22)

will be invoked.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

Figure 7-22: Resolve acute sinusitis Action Confirmation List.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 12 – Patient has reported taking all the amoxicillin;

there is no reason to discontinue order. – Locate and click on down arrow next to

“Cancel;” select “Clear This Therapy” from drop-down list (Figure 7-22).

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 12 (cont.) – Click on button labeled “Take All Actions That

Are Checked.” – When you have completed this step, notice

that both problems are now in inactive problem list.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 13 – Remain on Manage tab. – Click on Print button on Toolbar at top of your

screen to invoke Print Data window. – Be certain there is check mark in box next to

“Current Encounter;” also put check mark in box next to “Problem List” (Figure 7-23).

– Click on button to either print or export a file.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

Figure 7-23: Check mark next to Problem List in Print Data window.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 45: Following Up on a Problem

• Step 13 (cont.) – Compare your printout or file output to Figures

7-24a and 7-24b in the textbook. – If it is correct, hand it in to your instructor. – If there are any differences, review previous

steps in exercise and find your error.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Orders and Results Management

• Benefits of CPOE Order Tracking – Prevent lost orders. – Prevent duplicate orders. – Detect when patient sent to outside lab has

failed to show up.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Orders and Results Management

• Benefits of Results Tracking – Notify provider as soon as “preliminary”

results are available. – Notify provider anytime results status are

updated to “final” or “corrected.” – Keeps track of which results need to be

reviewed by clinician.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Orders and Results Management

• Benefits of Results Tracking (cont.) – Ability to graph or “trend” results. – Ability to review results online; to quickly order

subsequent or additional tests when warranted.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Case Study – In Guided Exercise 42 this patient's mother

reported the possible exposure to lead-based paints while remodeling their older home. You will recall her treatment plan recommended screening other family members.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Case Study (cont.) – The clinician has since ordered tests for her

son Stanley and he has already visited the lab before his appointment. Today is his office visit for examination and to review the test results.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 1 – Start Student Edition

software. – Click Select on Menu

bar; then click Patient. – In Patient Selection

window, locate and click on Stanley Zabroski.

Figure 7-25: Selecting Stanley Zabroski from the Patient Selection Window.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 2 – Click Select on Menu

bar; then click New Encounter.

– Select date May 22, 2012, time 4:00 PM, reason Office Visit.

– Make certain date and time match before clicking on OK button.

Figure 7-26: New encounter for an office visit, May 22, 2012 4:00 PM.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 3 – Enter the Chief

complaint. – Click button in toolbar

labeled “Chief.” – In dialog window that

will open, type “Rule out lead poisoning.”

– Click button labeled “Close the note form.”

Figure 7-27: Chief complaint dialog for “Rule out lead poisoning.”

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 4 – Enter vital signs for

Stanley Zabroski using the Vitals Form.

– When finished, click on tab labeled Encounter at bottom of window.

Temperature: 98.6

Respiration: 20

Pulse: 76

BP: 120/80

Height: 73

Weight: 155

Stanley's vital signs:

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

Figure 7-28: Vital Signs form for Stanley Zabroski.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 5 – Click on Dx Tab. – Click on button labeled

“Search” on Toolbar near top of screen.

– Search String window invoked.

– Enter search string “Lead poisoning;” click on button labeled “Search” in window. Figure 7-29: Search for Lead

Poisoning.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 6 – Click on Dx tab. – Locate and highlight finding “POISONING

HEAVY METALS LEAD.” – Click on List Size button until list size is 1. – Compare your screen to Figure 7-30; then

click on button labeled “Prompt” on Toolbar near top of screen.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

Figure 7-30: Search results with Poisoning Heavy Metals Lead highlighted.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 7 – Click on Sx tab. – Verify that List Size is set to 1. – Click on button labeled “ROS” on Toolbar

near top of screen. – Click on button labeled “Negs” (Auto

Negative) on Toolbar near top of screen. – Compare your screen to Figure 7-31.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

Figure 7-31: Symptoms for Heavy Metal Poisoning Lead.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 8 – Click on Hx tab. – Locate and click on following finding:  House has peeling paint which is lead based (red

button) – Compare your screen to Figure 7-32.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

Figure 7-32: History for Heavy Metal Poisoning Lead.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 9 – Click on Px tab. – Locate and click on Following finding:  Gums gingival line (blue button)

– Compare your screen to Figure 7-33.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

Figure 7-33: Physical Exam for Heavy Metal Poisoning Lead.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 10 – Patient had several lab tests performed

before office visit; results were within normal limits.

– Review results and document in encounter note.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 10 (cont.) – Click on Tx tab; locate and click on following

finding:  CBC with differential (blue button)  Serum Lead Level (blue button)  Urine Lead, 24 hr (blue button)

– Compare your screen to Figure 7-34. – If it is correct, click on tab labeled “Manage” at

bottom of window.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

Figure 7-34: Tx tab showing test results with normal results.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 11 – Your screen should display Problem List. – If information pane on left of screen is not

displaying Problem List, click on tab labeled “Problem List.”

– If Entry Details pane is covering part of list, locate and click on button labeled “Details” in Toolbar at top of screen.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 11 (cont.) – Click Select on Menu bar; then click Pending

Orders. – Window of pending orders will be displayed. – Compare window in screen labeled “Pending

Orders for Stanley Zabroski” to Figure 7-35. – Window contains list of tests ordered but

results have not yet been entered.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

Figure 7-35: Patient Management—Pending Orders window.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 11 (cont.) – Close window by clicking on Cancel button. – Note: If you click OK by mistake, you will

invoke results entry window. – Click Cancel button in that window; proceed

to the next step.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 12 – From Manage tab, you can see results of

tests that have been entered. – Provider notified that results ready for review. – In Problem List in left pane of screen under

test column, test names in bold type indicate those that have results in system.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 12 (cont.) – Position mouse over test labeled “Ordered

CBC;” click Right button on mouse. – Drop-down list displayed. – If drop-down list does not match list shown in

Figure 7-36, your mouse was not positioned correctly on test.

– Reposition mouse; click right mouse button again.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

Figure 7-36: Right-click menu: “Shows Results” invokes window of ordered CBC results.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 12 (cont.) – Locate option to Show Results; click left

mouse button. – Window displaying “Results for Ordered CBC”

displayed (Figure 7-36). – Clinician can review actual test results. – Click Cancel button to close results window.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 13 – Position mouse over test labeled “Ordered

Basic Metabolic Panel;” click Right button on mouse.

– Drop-down list displayed. – Without clicking on any options, look at list

displayed.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 13 (cont.) – In addition to “Show Results” option, drop-

down list options include ability to reorder test, order follow-up tests, enter status of test into current encounter.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 13 (cont.) – Locate and highlight

option “Results Pending” in the drop- down list

– Click left mouse button.

– This will record finding into exam narrative that test results are pending. Figure 7-37: Select option Results

Pending for basic metabolic panel.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 14 – Locate and click on Encounter tab at bottom

of screen. – Click on Dx tab. – Click on Search button in Toolbar at top of

screen. – Search String window Click on button in

window labeled “Search.” (Refer to Figure 7- 29.)

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 14 (cont.) – invoked; should still contain words “lead

poisoning;” if not, type them again. – When list of diagnoses displayed, locate and

highlight finding “POISONING HEAVY METALS LEAD.” (Refer to Figure 7-30.)

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 14 (cont.) – In Entry Details section at bottom of screen,

locate Status Field; click on down arrow button in it.

– Scroll drop-down list displayed to locate and click on “ruled out” (Figure 7-38).

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

Figure 7-38: Dx tab—Select status “Ruled out” for Poisoning Heavy Metals Lead.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 15 – Click on Print button on Toolbar at top of

screen to invoke Print Data window. – Be certain there is check mark in box next to

“Current Encounter;” then click on button to either print or export a file.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 46: Viewing Pending Orders and Lab Results

• Step 15 (cont.) – Compare your printout or file output to Figure

7-39 in the textbook. – If correct, hand it in to your instructor. – If there are differences, review previous steps

in exercise and find your error.

Slide Number 1
Longitudinal Patient Records to Manage Patients' Health
Longitudinal Patient Records to Manage Patients' Health
Understanding Problem Lists
Understanding Problem Lists
Understanding Problem Lists
Guided Exercise 44:�Exploring Patient Management
Guided Exercise 44:�Exploring Patient Management
Guided Exercise 44:�Exploring Patient Management
Guided Exercise 44:�Exploring Patient Management
Guided Exercise 44:�Exploring Patient Management
Guided Exercise 44:�Exploring Patient Management
Guided Exercise 44:�Exploring Patient Management
Guided Exercise 44:�Exploring Patient Management
Guided Exercise 44:�Exploring Patient Management
Guided Exercise 44:�Exploring Patient Management
Guided Exercise 44:�Exploring Patient Management
Guided Exercise 44:�Exploring Patient Management
Guided Exercise 44:�Exploring Patient Management
Guided Exercise 44:�Exploring Patient Management
Guided Exercise 44:�Exploring Patient Management
Guided Exercise 44:�Exploring Patient Management
Guided Exercise 44:�Exploring Patient Management
Guided Exercise 44:�Exploring Patient Management
Guided Exercise 44:�Exploring Patient Management
Guided Exercise 44:�Exploring Patient Management
Guided Exercise 44:�Exploring Patient Management
Guided Exercise 44:�Exploring Patient Management
Guided Exercise 44:�Exploring Patient Management
Citing Previous Visits from �Problem Lists
Citing Previous Visits from �Problem Lists
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Guided Exercise 45: �Following Up on a Problem
Orders and Results Management
Orders and Results Management
Orders and Results Management
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results
Guided Exercise 46: Viewing Pending Orders and Lab Results