Medical Assisting 5e / EHR Exercises OLC
Patient B Profile

Patti Adams is a 58 year old, married woman, born 06/25/1955. The patient’s preferred language is English, her race is African-American, and her ethnicity is Hispanic. Patti is an established patient who lives in Sherman, Texas. She lives with her husband and works at Flagler Technical Institute. The patient's past medical history includes left breast biopsy (2008), appendectomy (2001), occasional flu and sinus allergies, three pregnancies (G3), two live children (P2), and one miscarriage. Patti has a current diagnosis of hypertension. She arrives at the clinic today complaining of painful swelling on her left thigh.

Exercise 1B: Building a Patient’s Face Sheet

In this exercise you will add Patti Adam’s past medical history and the family health history to the face sheet of the electronic chart.

  1. Click one time on the patient Patti Adams located on the office calendar.
  2. In the Edit Appointment window click on the [Get Chart] button, seen in Figure B1.

Figure 1 Edit Appointment window.

  1. In the patient’s electronic chart, click on the show chart/face sheet icon located to the right of the menu bar (illustrated in margin).

Show chart/face sheet icon (COMP: MARGINAL ILLUSTRATION)

  1. In the face sheet window click on the [PMHX] navigation button.
  2. Type in the following information into Other PMHX window:

·  Pregnancies: Gravida 3, Para 2

·  Appendectomy - December 2001

·  Left breast biopsy 2008. Negative results

·  Occasional flu and/sinus allergy

·  Staff member: (Type your name here)

  1. In the Dx field in the upper right section of the screen type flu then click the search binoculars icon (illustrated in margin). Select Flu 487.1.

Dx field and search binoculars icon (COMP: MARGINAL ILLUSTRATION)

  1. In the face sheet window click on the [FMHX] navigation button.
  1. Click in the Other FMHX window. Now in the Preferences window, click on the following items:

Note: After the selection of an item from the Preferences window, place the cursor after the item before selecting the next entry. By placing the cursor after the selected word you are telling the system where to place the next entry. You will need to type in the various ages as noted. (COMP: SET NOTE IN BORDER)

·  Mother: Died at Age: 67. Cause of Death: MI.

·  Father: Colon Cancer. Alive at age: 83

·  Brother: Alive at age: 60. Hypothyroidism.

·  Sister: Alive at age: 54. In good health

  1. Click on the [Back] button located in the lower left corner of the face sheet window. Notice the new information displayed in the patient’s face sheet portion of the electronic chart, seen in Figure B2.

Figure 2 PMHX and FMHX in face sheet of patient's chart.

  1. Click on the File menu in the patient’s chart and select the submenu Print Face Sheet, seen in Figure B3.

Figure 3 Print Face Sheet submenu.

  1. Select the [Print] button in the Document Printing Options window. Print out your document. Locate and circle your name in the PMHX section of the Face Sheet report. Turn in your document to your instructor.
  2. Close the patient’s chart by clicking the ‘X’ in the upper right hand corner. Close the Edit Appointment by clicking on the ‘X’ in the upper right hand corner.

Note to Instructor: On the printed patient’s face sheet that the students turn in you will be looking for the following:

1.  The students name circled at the end of the PMHX section.

2.  The Flu diagnoses in the PMHX section.

3.  The description of pregnancy history, appendectomy, breast biopsy, flu, and sinus allergy in the PMHX section.

4.  The family healthcare data in the FMHX section.

Exercise 2B: Building a Patient’s Office Visit Note

In this exercise you will add the chief complaints to an office visit note.

  1. Repeat steps 1 and 2 in Exercise 1B.
  2. In the patient’s chart, click on the ‘+’ sign to the left of the Encounter category in the upper right section of the chart. Click on the Office Visit note dated 05/06/2013.
  3. In the lower right section of the window, click on the [Edit] button to open the Office Visit note (illustrated in margin).

Edit button in patient’s chart (COMP: MARGIN ILLUSTRATION)

  1. The Office Visit (OV) screen will open and default to the Chief Complaint section. Sometimes the patient’s complaints do not match the available pop-up text. In that case you will need to type text directly into the Chief Complaint area. Type the follow text: Pt c/o trouble sleeping and painful area on inside of left thigh., as seen in Figure B4.
  2. Skip a line in the lower Chief Complaint window and type the following:

·  Staff member: (Type your name here), also seen in Figure B4.

  1. Click the [Done] button in the lower section of the screen. Click the [Save and Skip Billing] button in the Save As window, as seen in Figure B5. Close the patient’s chart and close the Edit Appointment window.

Figure 4 Adding text in OV note.

Figure 5 Save and Skip Billing button.

Exercise 3B: Recording and Viewing Vitals

In this exercise you will record the patient’s vital signs in the OV note.

  1. Repeat steps 1 through 3 in Exercise 2B
  2. Click on the Vitals navigation tab on the right hand side of the screen.
  1. Record the following vitals in the lower middle section:

·  Temperature: 98.4, Respiration: 22, Pulse: 84, Blood pressure: 144/88, Height: 5 ft 4 ins (convert to inches), Weight: 165 lbs

  1. Click on the show chart summary navigation tab (illustrated in margin). Scroll down through the OV note and notice the recording of the vitals under the Objective section of the SOAP note, seen in Figure B6. Notice that the BMI (Body Mass Index) is automatically calculated from the height and weight of the patient.
  2. Click the [Done] button in the lower section of the screen. Click the [Save and Skip Billing] button in the Save As window. Close the patient’s chart and close the Edit Appointment window.

Show chart summary navigation tab (COMP: MARGIN ILLUSTRATION)

Figure 6 Vitals recorded in OV note.

Exercise 4B: Ordering Tests and Documenting Procedure in an OV Note

In this exercise you will order the following tests within the office visit note: Lipid Panel and CMP (Complete Metabolic Panel). you

1.  Repeat steps 1 through 3 in Exercise 2B.

2.  In the Navigation panel to the far right, click on the Test navigation tab.

3.  In the TEST field in the upper right panel type: lipid and conduct a search by clicking on the binoculars icon. Click on the displayed Lipid Panel 80061 from the database which will move it down to the lower Selected Tests window, as seen in Figure B7.

Figure 7 Ordering tests in the OV screen.

4.  Repeat the previous step by searching for and selecting a CMP.

5.  Both tests should now appear in the Selected Tests window. Now click on the [Ordered Selected Tests] button in the lower right section of the screen (illustrated in margin). This will send the tests into the OV note and place the tests in a pending area of the program where they await entry of results.

Order selected tests button (COMP: MARGIN ILLUSTRATION)

  1. Click on the Proc navigation tab on the right hand side of the screen (illustrated in margin).

Procedure navigation tab (COMP: MARGINAL ILLUSTRATION)

  1. Click on the I&D procedure in the lower Procedures section of the OV note, seen in Figure B8.

Figure 8 CPT Name in Procedures section.

  1. In the Edit procedure window, click on the pop-up text that begins: The patient's questions were answered. The entire paragraph will be placed in the text area, as seen in Figure B9.

Figure 9 Selecting pop-up text in Edit Procedure window.

9.  On the next line in the text area, type the following: Assisted with incision and drainage of area on left thigh. Culture obtained and sent to MedLab. Then click the [D & T] and the [Initials] buttons (illustrated in margin) to add the date, time, and your initials to the procedure note.

Note: In a regular EHR program, each user that logs into the program will have initials and other details associated with the user set up in the program. Thus, when the [Initials] button is activated the program will stamp the unique initials associated with the user onto the note.

Date, Time, and Initials buttons (COMP: MARGINAL ILLUSTRATION)

  1. Click the [Save] button in the Edit Procedure window. Click the [Done] button in the lower section of the screen. Click the [Save and Skip Billing] button in the Save As window. Close the patient’s chart and close the Edit Appointment window.

Exercise 5B: Administrating a Patient Instruction

In this exercise you will be selecting an appropriate patient education sheet to administer to the patient.

  1. Repeat steps 1 through 3 in Exercise 2B.
  2. Click on the Other Tx (Other Treatment) navigation tab..
  3. From the Other Tx popup text panel select the phrase that begins with: Pt education performed for wound care. Then select the phrase: Patient and parent had no questions to send the text into the OV note, as seen in Figure B10.

Figure 10 Selecting popup text in Other Tx panel.

  1. Click on the Tools menu and select the Patient Instructions submenu, seen in Figure B11.

Figure 11 Patient Instructions submenu in OV screen.

  1. From the Choose Patient Instruction window, select the Wound Care instruction sheet.
  2. At the bottom of the patient instruction type your name after Issuing Staff Member: as seen in Figure B12.

Figure 12 Typing on to the patient instruction sheet.

  1. Print out the document, circle your name, and turn into your instructor.
  2. Notice in the Other Treatment note that the system automatically stamped the OV note with: Pt Instr: Wound Care given to document that you printed the patient instruction for the patient.
  3. Click on the [Print] button at the bottom of the OV screen (illustrated in margin) and print out the OV note. Circle your name in the Subjective area at the top and turn in to your instructor.

Print button in OV screen (COMP: MARGIN ILLUSTRATION)

  1. Click the [Done] button in the lower section of the screen. Click the [Save and Skip Billing] button in the Save As window. Close the patient’s chart and close the Edit Appointment window.

Note to Instructor:

A.  On the printed patient instruction sheet you will be looking for the following:

1.  The student’s name circled at the bottom of the form.

B.  On the printed patient’s office visit note that the students turn in you will be looking for the following:

1.  The patient’s chief complaint.

2.  The student name circled in the Subjective area of the note.

3.  The patient’s vitals under the Objective area of the note.

4.  The two ordered tests under the Plan area of the note.

5.  The appropriate notation under the Procedures section of the Plan area along with the date, time, and initials.

6.  The recorded data in the Other Treatment section of the Plan and that the patient instruction sheet Wound Care was given to the patient.

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