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 TWO

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

Trending

• Trending: comparing change of certain test components or measurements over period of time.

• Data stored in EHR, computer can instantly find all instances of any component to be compared.

• Graphs and charts can be easily created.

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

Guided Exercise 47: Graphing Lab Results

• Case Study – Guy Daniels has been seen at the clinic for

several years. He has hypertension, Type II diabetes, and a weight problem.

– He is scheduled for a clinic visit tomorrow and his pre-visit lab work has been received from the lab.

– You have been asked to generate two graphs to be used for patient education.

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

Guided Exercise 47: Graphing Lab Results

• Step 1 – Start Student Edition

software. – Click Select on Menu

bar; then click Patient. – In Patient Selection

window, locate and click on Guy Daniels.

Figure 7-40: Selecting Guy Daniels from the Patient Selection window.

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

Guided Exercise 47: Graphing Lab Results

• Step 2 – In this exercise you are going to retrieve and

work with an encounter already in progress. – Click Select on Menu bar; then click Existing

Encounter. – Small window of previous encounters

displayed. – Compare your screen to window in center of

Figure 7-41.

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

Guided Exercise 47: Graphing Lab Results

Figure 7-41: Select Existing Encounter for May 23, 2012 10:00 AM.

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

Guided Exercise 47: Graphing Lab Results

• Step 2 (cont.) – Position your mouse pointer on first encounter

in list, dated 5/23/2012 1:35 PM (Figure 7-41) and click on it.

– This encounter is simply the result record of a number of tests that were ordered before Mr. Daniel's scheduled visit.

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

Guided Exercise 47: Graphing Lab Results

• Step 3 – Click on Tx Tab. – Click on button labeled “Search” on Toolbar

near top of screen. – Search String window invoked. – Type search string “Creatinine;” click on

button in window labeled “Search” (Figure 7- 42).

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

Guided Exercise 47: Graphing Lab Results

Figure 7-42: Search for Creatinine.

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

Guided Exercise 47: Graphing Lab Results

• Step 4 – Left pane should automatically be on Tx tab. – Locate and highlight finding of Serum

Creatinine (Figure 7-43). – Click Graph on Menu bar; then click “Current

Finding” from drop-down list. – The Medcin Graph window will be invoked.

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

Guided Exercise 47: Graphing Lab Results

Figure 7-43: Select Graph Current Finding from menu.

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

Guided Exercise 47: Graphing Lab Results

• Step 5 – Software will find and graph Mr. Daniel's

creatinine over last four tests. – Compare your screen to Figure 7-44. – This example shows increase in creatinine

level. – Similar graphs could have been created for

any lab results that have numeric values for their results.

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

Guided Exercise 47: Graphing Lab Results

Figure 7-44: Graph of Guy Daniel's serum creatinine.

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

Guided Exercise 47: Graphing Lab Results

• Step 6 – Graph window has two buttons in upper left

corner that are identical in appearance and purpose to corresponding buttons on Student Edition Toolbar.

– First button is Exit; closes graph window. – Second button is Print button; prints graph.

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

Guided Exercise 47: Graphing Lab Results

• Step 6 (cont.) – Locate and click on Print button (circled in

Figure 7-45) in upper left corner of graph window to invoke Print Data window.

– In left column of Print Data window you will see a check box with name of graph.

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

Guided Exercise 47: Graphing Lab Results

Figure 7-45: Print Data window for Graphs is invoked from Graph window Print icon.

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

Guided Exercise 47: Graphing Lab Results

• Step 6 (cont.) – Click your mouse in check box next to Serum

Creatinine; then click on button to either print or export file.

– When graph has printed, click on Exit button in window displaying Serum Creatinine graph.

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

Guided Exercise 48: Graphing Vital Signs in the Chart

• Step 7 – In right pane, encounter note, locate and click

on vital sign Blood Pressure (Figure 7-46). • Step 8

– Click word “Graph” on Menu bar; then click “Current Finding” on list of menu options.

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

Guided Exercise 48: Graphing Vital Signs in the Chart

Figure 7-46: Selecting Guy Daniels blood pressure from encounter.

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

Guided Exercise 48: Graphing Vital Signs in the Chart

• Step 9 – Software will find and graph Guy's blood

pressure over last four visits. – Compare your screen to Figure 7-47. – Blue line is systolic blood pressure readings;

green line is diastolic readings, noted in graph legend, SBP and DPB, respectively.

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

Guided Exercise 48: Graphing Vital Signs in the Chart

Figure 7-47: Blood pressure graph for Guy Daniels.

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

Guided Exercise 48: Graphing Vital Signs in the Chart

• Step 9 (cont.) – Locate and click on Print button in upper left

corner of graph window to invoke Print Data window.

– Be certain there is check in box next to Blood Pressure; then click on button to either print or export file.

– When graph has printed, click on exit button in window displaying graph.

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

Guided Exercise 48: Graphing Vital Signs in the Chart

• Step 10 – For some vital signs it is not

necessary to locate finding to generate a graph.

– In this example the nurse wants to print a graph of patient's weight to use for weight counseling.

– Click word “Graph” on Menu bar; then click “Weight” on list of menu options. Figure 7-48 Select Weight

from the Graph menu.

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

Guided Exercise 48: Graphing Vital Signs in the Chart

• Step 11 – Compare your screen to Figure 7-49. – Graph of patient's weight measurements from

previous visits is instantly displayed. – You do not have to select a finding or even

load an existing encounter. – Graph menu allows clinician to instantly

create graphs of several key measurements without having to locate a specific finding.

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

Guided Exercise 48: Graphing Vital Signs in the Chart

Figure 7-49: Graph of change in Guy Daniels's weight.

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

Guided Exercise 48: Graphing Vital Signs in the Chart

• Step 12 – Locate and click on Print button in upper left

corner of graph window to invoke Print Data window.

– Locate check box for Weight, in left column; click on it.

– Locate and click on button to print or export a file.

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

Guided Exercise 48: Graphing Vital Signs in the Chart

• Step 12 (cont.) – When graph has printed, click on exit button

in window displaying Weight graph. – Hand graphs in to your instructor.

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

Critical Thinking Exercise 49: Graphing Total Cholesterol and Weight

• Case Study – The clinic has been helping Sally Sutherland

monitor her cholesterol by testing her at each annual exam.

– In this exercise, you are going to create a graph of Sally's total cholesterol and her weight. You will not enter any new data.

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

Critical Thinking Exercise 49: Graphing Total Cholesterol and Weight

• Step 1 – If you are continuing from previous exercise,

proceed to select the patient; otherwise start Student Edition software.

– Click Select on Menu bar; then click Patient. – In Patient Selection window, locate and click

on Sally Sutherland. – You do not have to set date or time.

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

Critical Thinking Exercise 49: Graphing Total Cholesterol and Weight

• Step 2 – Click word “Graph” on Menu bar; then click

“Weight” on list of menu options. • Step 3

– Locate and click on Print button in upper left corner of graph window to invoke Print Data window.

– Locate check box for Weight in left column and click on it.

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

Critical Thinking Exercise 49: Graphing Total Cholesterol and Weight

• Step 3 (cont.) – Locate and click on button to print or export

file. – When graph has printed, click on exit button

in window displaying Weight graph. – Click on Exit button in window displaying

weight graph.

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

Critical Thinking Exercise 49: Graphing Total Cholesterol and Weight

• Step 4 – Locate and click button labeled “Search” on

Toolbar to invoke Search String window. – Type words “Total Cholesterol” in Search

String window; click on Search button.

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

Critical Thinking Exercise 49: Graphing Total Cholesterol and Weight

• Step 5 – Verify you are on Tx tab. – Locate and highlight finding of Total

Cholesterol. – Click Graph on Menu bar; then click “Current

Finding” from dropdown list. – Graph window invoked, displaying a graph of

Sally's Total Cholesterol test results over last four years.

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

Critical Thinking Exercise 49: Graphing Total Cholesterol and Weight

• Step 6 – Locate and click on Print button in upper left

corner of graph window to invoke Print Data window.

– Locate check box for Total Cholesterol in left column; click on it.

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

Critical Thinking Exercise 49: Graphing Total Cholesterol and Weight

• Step 6 (cont.) – Locate and click on button to print or export

file. – When graph has printed, click on Exit button

in window displaying Total Cholesterol graph. – Hand graphs in to your instructor.

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

Chapter Summary

• This chapter explored the Patient Management feature to demonstrate the way an EHR can organize information from past encounters.

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

Chapter Summary

• Patient Management Tabs: – Problems – Care Plan – Medications – Vaccines – Allergies

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

Chapter Summary

• Patient Management Tabs: – Past Medical/Surgical History – Family History – Social History – Vitals

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

Chapter Summary

• Patient Management feature allows information from previous encounters to be updated and cited in current encounter.

• Citing: to bring a finding from a previous encounter note into current encounter.

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

Chapter Summary

• All lab orders have a status. – Ability for clinician to see what tests are

pending helps prevent duplicate orders. • Ability to graph weight, height, and test

results can provide excellent means of clarification when counseling patients.

Slide Number 1
Trending
Guided Exercise 47: �Graphing Lab Results
Guided Exercise 47: �Graphing Lab Results
Guided Exercise 47: �Graphing Lab Results
Guided Exercise 47: �Graphing Lab Results
Guided Exercise 47: �Graphing Lab Results
Guided Exercise 47: �Graphing Lab Results
Guided Exercise 47: �Graphing Lab Results
Guided Exercise 47: �Graphing Lab Results
Guided Exercise 47: �Graphing Lab Results
Guided Exercise 47: �Graphing Lab Results
Guided Exercise 47: �Graphing Lab Results
Guided Exercise 47: �Graphing Lab Results
Guided Exercise 47: �Graphing Lab Results
Guided Exercise 47: �Graphing Lab Results
Guided Exercise 47: �Graphing Lab Results
Guided Exercise 48: �Graphing Vital Signs in the Chart
Guided Exercise 48: �Graphing Vital Signs in the Chart
Guided Exercise 48: �Graphing Vital Signs in the Chart
Guided Exercise 48: �Graphing Vital Signs in the Chart
Guided Exercise 48: �Graphing Vital Signs in the Chart
Guided Exercise 48: �Graphing Vital Signs in the Chart
Guided Exercise 48: �Graphing Vital Signs in the Chart
Guided Exercise 48: �Graphing Vital Signs in the Chart
Guided Exercise 48: �Graphing Vital Signs in the Chart
Guided Exercise 48: �Graphing Vital Signs in the Chart
Critical Thinking Exercise 49: Graphing Total Cholesterol and Weight
Critical Thinking Exercise 49: Graphing Total Cholesterol and Weight
Critical Thinking Exercise 49: Graphing Total Cholesterol and Weight
Critical Thinking Exercise 49: Graphing Total Cholesterol and Weight
Critical Thinking Exercise 49: Graphing Total Cholesterol and Weight
Critical Thinking Exercise 49: Graphing Total Cholesterol and Weight
Critical Thinking Exercise 49: Graphing Total Cholesterol and Weight
Critical Thinking Exercise 49: Graphing Total Cholesterol and Weight
Chapter Summary
Chapter Summary
Chapter Summary
Chapter Summary
Chapter Summary