Health Information Systems and the Electronic Health Record

Overview

This activity is intended for the intermediate and advanced EHR student users. The student will document in the EHR, evaluate the documentation methods of the EHR, reviewing the system’s functionality and usability, reporting capabilities and health record management. The focus is on notes, medications, lab management, decision support, and reports.

Prerequisites

1. Completion of Neehr Perfect Scavenger Hunts Levels I-III

2. Completion of Neehr Perfect activities:

1. Neehr Perfect Activity: Data Entry

2. Neehr Perfect Activity: Communication within the EHR

Student instructions

1. If you have questions about this activity, please contact your instructor for assistance.

2. Document your answers directly on this document as you complete the activity. When you are finished, save this 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.

3. Screen displays are provided as a guide and some data (e.g. dates and times) may vary.

Objectives

1. Demonstrate skill to document timely and efficiently in the EHR.

2. Differentiate between the different types of EHR templates.

3. Identify different forms of EHR functionality.

4. Demonstrate the ability to build a customized report.

The activity

Dr. Carter is the medical director of an Inpatient Rehab Facility. He has switched from paper records to an electronic health record. You are employed at the Rehab Facility and are tasked with evaluating the documentation methods of the EHR. You will review the system’s functionality and usability, reporting capabilities and health record manageability.

Log in to the EHR and open your portfolio chart (the chart named with your first and last name and the word "Portfolio").

1. Analyze templates (notes)

Once inside of your portfolio chart, click on the Help menu. Choose Contents. In the Index, type Template under 1. Then choose Types of under 2. and click on Display and read about document templates. Click the X in the upper right corner of the CPRS Help File box to close the window when you’re done.

Next, click on the Notes tab of the EHR and select New Note. You will now test different notes in the EHR.

In the Progress Note Title section, type in Vitals and select the note NURS: VITALS ASSESSMENT. Select your instructor as the cosigner and click OK to open the note template. Complete the note based on the following information and click OK when you are done.

Date and Time of Assessment: Current date/time

Temp: 96.4 F, Oral

Pulse: 75, Radial

Respirations: 14, Spontaneous

BP: 140/60, Sitting, Right Arm, Reg Adult

SP02: 98%, Room Air

Pain: 5/10, dull, aching

Ht: 66 inches

Wt: 170 pounds

Intake: 600ml, this shift

Output: 420ml, this shift

Sign the note when you are done by right-clicking in the body of the note and choosing Sign Note Now.

Now go to the Cover Sheet and select File > Refresh Patient Information.

1. Did the vital signs you just entered in your note populate on the vital signs section of the cover sheet?

Now return to the Notes tab and select New Note again to pull up the search box. In the Progress Note Title box, type Untemplated and select the note: NURS: PROGRESS NOTE (UNTEMPLATED). Select your instructor as the cosigner and then click OK. Type a simple statement of your choice in the note. Then right-click in the body of the note and choose to Save Without Signature. Now edit the note using the Action menu or by right clicking in the middle of the note and selecting Edit Progress Note. Type in another simple statement. Choose to Save without Signature again.

1. Go to File > Refresh Patient Information. What happens?

Sign the note using your Neehr Perfect username.

Select New Note again. Type EST and select MED: EST PT H&P. Select your instructor as the cosigner and click OK. Click the white boxes and buttons in the template to examine the entire contents, filling out some of the fields with text and checking some of the check boxes. Click OK when you are done. Choose to Sign Note Now.

Charting analysis questions

1. Does the system offer a variety of notes?

2. Does the system alert about unsigned notes?

3. What improvements or changes would you make to the charting aspects of this EHR?

1. Analyze medications

Still in your portfolio chart, go to the Help menu. Choose Contents. In the Index, type Medications under 1. Then choose Ordering Inpatient under 2. and click on Display. After reading this information, click on the link Viewing Medications at the bottom and read the information provided. Click the X in the upper right corner of the CPRS Help File box to close the window when you’re done.

Go to the Orders section of the chart and select Inpatient Unit Dose Meds on the left side of the screen. You may be prompted to choose an Encounter Provider. If so, choose your instructor from the drop-down list of Providers and click OK. Note the medications on the medication selection screen. Choose Order any Inpt Med.

Scroll down and review the extensive number of medications in the formulary.

Type in Tylenol and select the Tylenol ACETAMINOPHEN TAB. Complete the order by selecting any of the doses, the route of Oral and a frequency of Q4H. Select Accept Order. Note any order checks and click Accept Order. Repeat the above steps and order the following drugs:

1. 1. 1. Fluoxetine cap oral 20mg Oral QAM

      2. Ranitidine tab 150mg Oral BID

Exit the medication order set by selecting Quit and Done.

Go to File > Refresh Patient Information. Choose Signed on Chart and click OK. Then sign the orders by typing in your username. Note any order checks.

Go to the Tools section on the top toolbar. Select Drug Information Portal. Find and review information on Ranitidine.

Medication analysis questions

1. Can you access outside resource information from the EHR?

2. Does the system use an order check system?

3. Explain the importance of having outside resources available to the user.

4. Explain why having an internal checking system within the EHR is so important.

1. Analyze lab results management

Remain in your portfolio chart, select Help > Contents. In the Index, type Lab under 1. Then choose Ordering under 2. and click on Display. After reading this information, click on the link Viewing Laboratory Test Results at the bottom and read the information provided. Click the X in the upper right corner of the CPRS Help File box to close the window when you’re done.

Next, click on the Orders tab of the chart and select Inpt Laboratory on the left panel.

From the initial screen on the Neehr Perfect Laboratory Menu, place an order for a CHEM 7 and CBC. Note: You may have to extend and enlarge the pop-up box so you can click Accept to place the order. Click Done when you are finished. Go to File > Refresh Patient Information. Check Release to Service and Per Policy and click OK. Sign the orders with your username.

Still on the Orders tab, this time select ORDER ANY PT LAB on the left panel. In the lab selection screen, type in Chem and select Chem 20 and click Accept Order. Note any order checks, if any, and click Accept Order again if prompted. Click Quit and Done to exit.

**Go to File > Select new patient. Open the patient chart of Olson,Warren.

On Warren’s Cover Sheet, review the lab section.

1. Left-click on the lab for Albumin Serum. What is the result?

Go to the Labs section of the chart. Select CUMULATIVE under the Lab Results section in the upper left. Then select ALL RESULTS under the Date Range section in the lower left to review the labs.

Lab management analysis questions:

1. Do the labs on the Labs tab list abnormal values and if it’s high or low?

2. Where else can you locate lab results in the chart?

3. For the lab orders you just entered in your portfolio chart, how do you know if the lab has been processed?

Analyze decision support and reporting

Go to the Help menu. Choose Contents. In the Index, type Reports. Then choose Viewing a Report and click on Display. After reading this information, click on the link Available Reports on the Reports tab.

While still in Warren Olsen’s chart, go to the Reports tab. Use the CLINICAL REPORT Function and expand each section by clicking on the “plus” sign.

Open the Progress Notes section and click on Progress Notes. Review the Medic Admit Note written by Doctor Eleven.

Next, open the Health Summary section and select Adhoc Report.

Create an Adhoc report containing:

1. 1. Brief Adv React/All [BADR]

   2. Detailed Vitals [VSD]

To create the report, select the desired item on the left of the screen and click on the > to move it to the right under Component Selections. Then press OK.

1. Copy and paste the Adhoc report here.

**Go to File > Select New Patient and select your portfolio chart.

In your portfolio chart, go to the Problems tab and click New Problem. You may be prompted to enter your Encounter Provider again. Select your instructor and click OK. Type in Diabetes. Select Diabetes (250.00). Complete the problem form by selecting Chronic and OK.

1. Return to the Cover Sheet. Are there any changes?

Go to the Allergy box on the Cover Sheet and right click to add a new allergy. Type in Penicillin and select it from the list. On the allergy form, pick allergy as the nature of the reaction and select any symptom. Select OK.

1. Return to the Cover Sheet. Are there any changes?

Decision support and reporting analysis questions

1. Does the system utilize clinical information from all parts of the chart to assist in decision support?

2. Does the system allow users to create any type of report based on the patient information in the chart?

3. If you could develop a daily report that provided you with updated information on your patient, what would you include from the Adhoc report options? List the items you would include.

Submit your work

Document your answers directly on this document as you complete the activity. When you are finished, save this 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.