Health Information Systems and the Electronic Health Record
Overview
This activity has been developed for the beginning and intermediate EHR student user. The student will learn basic data entry and documentation skills in the EHR to learn the skill of entering data in the patient medical record.
Prerequisites
Completion of Neehr Perfect Scavenger Hunts I-III
Student instructions
If you have questions about this activity, please contact your instructor for assistance.
Upon completion of this activity, take screenshot(s) of the work you completed in the EHR as directed and paste the screenshot(s) into a Word document. When you are finished, save the Word document and upload it to your Learning Management System (LMS). If you have any questions about submitting your work to your LMS, please contact your instructor.
Screen displays are provided as a guide and some data (e.g. dates and times) may vary.
Objectives
Identify and enter the appropriate problem and its assigned code.
Demonstrate documentation in the health record that is timely, complete, and accurate.
Apply data entry skills.
Glossary
Data: The raw facts and figures expressed in text, number, symbols and images.
Diagnosis: The name for the health problem that you have.
Diagnosis code: A code describing the principal diagnosis, additional conditions that coexisted at the time of admission, or developed subsequently, and which had an effect on the treatment received or the length of stay.
Electronic Health Record (EHR): Patient records that are maintained electronically in a manner that is accessible to caregiver, the patient and others who need access to specific information or to aggregate information to prevent illness and improve future treatment.
ICD: International Classification of Diseases (ICD) is the standard diagnostic tool for epidemiology, health management and clinical purposes. This includes the analysis of the general health situation of population groups. It is used to monitor the incidence and prevalence of diseases and other health problems. Example: ICD-9 789.7.
ICD-10: The 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. Example: ICD-10 R10.3
Inpatient: Health care a patient receives while admitted to a hospital.
Outpatient: Medical or surgical care that does not include an overnight hospital stay.
Problem: A current or a historical health care problem. Sometimes called a diagnosis or a “complaint”.
Vital signs: Clinical measurements, specifically pulse rate, temperature, respiration rate, blood pressure, oxygen saturation and pain assessment, that indicate the state of a patient's essential body functions.
The activity
Log in to the EHR and open your portfolio chart (the chart named with your first and last name and the word "Portfolio").
Enter a problem
Click on the Problems tab and then click on New Problem.
If you receive the prompt below, choose your instructor as the Encounter Provider. On the Hospital Admissions tab, select your PORTFOLIO INPT admission. Click OK.
Type in Portal Hypertension and click on Search.
Select the Portal Hypertension that includes an ICD-10 code.
Highlight the correct problem and click OK.
Choose Active and Chronic.
For Date of Onset enter 04/22/2012.
Scroll down to click on OK.
Enter orders
Click on the Orders tab.
Enter the order Activity as tolerated by following the steps below:
Click on PATIENT CARE in the left panel. Then select Text Only Order. Enter the order using free text: Activity as tolerated. Leave the Start Date/Time as NOW and do not enter a Stop Date/Time.
Click Accept Order. Then Quit. Click Done to leave this menu.
Enter the order Aspirin 325 mg by mouth daily by following the steps below.
Click on INPATIENT UNIT DOSE MEDS in the left panel. Then select Order Any Inpt Med. Begin typing aspirin. Select the ASPIRIN TAB. Select 325mg from the Dosage list. Leave as Oral. Select Daily from the Frequency list.
Click Accept Order. Then Accept Order again at the prompt. Then Quit. Click Done to leave this menu.
Now the orders need to be released so they can become part of the chart and the patient’s care. Follow the steps below to release them:
Highlight both orders with your mouse.
Click on the Action menu.
Choose Signature on chart.
If you receive an Order Check pop-up, click Continue.
Click OK to confirm the order.
Enter an allergy on the Cover Sheet
Click on the Cover Sheet tab.
Under the Allergies/Adverse Reactions section, right click on No Allergy Assessment.
Click on Enter new allergy.
Type in Latex and click Search. Under Drug Ingredients File, click on LATEX. Then OK.
For Nature of Reaction, choose Allergy.
For Signs/Symptoms click on Hives. It will be moved to ‘Selected Symptoms.’
Check the box for ID Band Marked. Then click OK.
Enter vital signs on Cover Sheet
While still on the Cover Sheet, click on No Data Found under the Vitals section. Or, if there are vital signs already in your portfolio chart, click on the top vital.
Click on the icon in the upper right, Enter Vitals.
Add the following vitals. Click on the down arrow under the Qualifiers section to provide more detail. Use today’s date and time.
Temperature: 101.6 F Oral
Pulse: 88 Apical, auscultate, sitting
Blood Pressure: 138/80, Left arm, cuff, sitting, adult
Respirations: 18 Spontaneous, sitting
Pain: 6/10
Weight: 170 lbs
Height: 66 inches
Pulse Oximetry: 98
Click Save and Exit.
To close the Vitals Lite window, select File > Exit at the top of that window.
Apply your knowledge
Using the step-by-step instructions used earlier in the activity as a reference, practice additional data entry below.
Add another problem
Using the same steps as above, enter a second problem of cellulitis of the left toe. This is an acute problem that just started yesterday, and is active.
Add another order
Using the same steps as above, enter another medication order. An inpatient unit dose medication needs to be ordered for cephalexin cap, 500 mg oral BID. Remember to release this order following the steps used for the earlier orders.
Add another allergy
Using the same steps as above, add an allergy for Codeine. It is a pharmacological reaction. The Signs/Symptoms are drowsiness and brachycardia. The ID band has been marked.
Add another vital sign
Using the same steps as above, enter a second blood pressure in the Vitals section. Enter a blood pressure of 122/68, taken in the right arm, while the patient was lying down with an adult cuff.
You will now take three screenshots of the data you just entered. Please take a screenshot of each of the areas listed below. Paste all screen shots in one Word document. Number them in the order listed below and submit that document to your instructor.
Screenshot of the Cover Sheet that includes the Allergies/Adverse Reactions section and the Vitals section. Be sure to include the yellow patient information box in the upper left corner that lists your portfolio name in the screenshot.
Screenshot of Problems listed on Problems tab. Be sure to include the yellow patient information box in the upper left corner that lists your portfolio name in the screenshot.
Screenshot of Orders entered on Orders tab. Be sure to include the yellow patient information box in the upper left corner that lists your portfolio name in the screenshot.
Submit your work
Upon completion of this activity, take screenshot(s) of the work you completed in the EHR as directed and paste the screenshot(s) into a Word document. When you are finished, save the Word document and upload it to your Learning Management System (LMS). If you have any questions about submitting your work to your LMS, please contact your instructor.
| Neehr Perfect EHR Activity: Data Entry v6 Archetype Innovations LLC ©2017 |
