Transcript EMR Chapter 6

Chapter 6
Clinical Use of the Electronic Health
Record
Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Lesson 6.1
Clinical Use of the Electronic Health
Record
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Describe the benefits of documentation in the electronic health
record (EHR).
Explain the role of speech recognition software in medical
documentation, and describe the benefits of the technology.
List the components of the medical, surgical, family, and social
history.
Explain how the chief complaint and history of the present
illness relate to each another.
Enter allergies, medications, and intolerances into an EHR.
Discuss what components of a patient's vaccination history
should be included in the chart.
Describe how to record vital signs and anthropometric
measurements in the EHR.
Outline the process many physicians use for constructing a
progress note.
Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.
2
Documentation in the Electronic
Health Record
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Makes diagnosis and treatment more efficient
Promotes patient safety and reduces medical
errors
Serves as a risk management function by
providing evidence of communication
Proper documentation in EHR allows related
items, such as health history, progress notes,
patient letters, and patient instructions, to be
linked
Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.
3
Voice Recognition
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Allows the user to work hands-free
Eliminates the problem of misplaced or
misfiled patient notes
Decreases the rate of transcription mistakes
Lowers the cost of transcription
Reduces the amount of time necessary to
complete documentation
Increases the overall quality of patient care
Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.
4
Documenting Remote PatientProvider Encounters
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Telephone documentation
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Med refills, sick calls, patient treatment questions
E-visits
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Web visit or online consultation
Monitoring chronic disease
Not for new patients
HIPAA-compliant online connection
Visit must be documented
Define time period for e-visit
Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.
5
Clinical Documentation in the Patient
Record
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In SimChart for the Medical Office (SCMO),
the patient visit is called an encounter
Three types of encounters:
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Comprehensive Visit
Office Visit
Phone Consultation
Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.
6
Allergies
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Document allergies:
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Environmental
Seasonal
Contact
Food
Verify at every visit
Document corresponding reactions
Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.
7
Documenting Patient History
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Medical and surgical history
Family history
Social history
Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.
8
Chief Complaint
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CC or cc
The patient’s main reason for seeking
medical care
Use the Record drop-down box to add new
CC
Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.
9
HPI
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Symptoms: What are the troublesome
symptoms (e.g., pain, breathing difficulties,
dizziness)?
Duration: How long has the patient had the
problem or illness?
Timing: Have the symptoms been persistent
or intermittent?
Modifying factors: What makes the symptoms
better or worse?
Associated signs and symptoms
Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.
10
Pain Scale
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“Fifth vital sign”
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Describes quality of pain on a scale of 1-10
Wong-Baker scale for children
Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.
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Problem List
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Part of meaningful use (MU) requirements
Allows provider to identify most significant
health concern
Identifies disease-specific populations
Helps to evaluate standard measures for
providers and organizations (MU program)
Identifies patients for possible research
studies
Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.
12
Medications
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Patients may be on medications from more
than one provider
Vital to keep the medication record current
Record reasons for discontinuing medications
Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.
13
Immunization History
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Document both childhood and adult
immunizations
EHR is a good tool for tracking immunization
history, and when new immunizations are due
Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.
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Immunization Documentation
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Name of
immunization
Name of person
administering the
immunization
Date given
Location of injection
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Category
Manufacturer
Type
Expiration date
Lot number
Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.
15
Using the EHR for Patient Education
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The EHR contains health data collected over a long
time, allowing the attentive clinician to identify longterm trends that indicate elevated disease risk
Guidelines for effective patient education:
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Speak with the patient in a quiet, well-lit area that offers as
much privacy as possible
Take your time and don’t rush as you explain the material
Provide both oral instructions and supplemental printed
instructions from the EHR
Encourage the patient to ask questions as needed
Have the patient and caregiver demonstrate skills before
leaving the office to ensure that proper technique is used
Encourage patients to contact the office at any time with
additional questions
Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.
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Vital Signs
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Recorded at the start of every visit
Anthropometric measurements
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Height, weight, BMI, head circumference
Vital signs: temperature, B/P, pulse, and
respirations
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17
The Progress Note
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S: Subjective
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O: Objective
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Information that can be observed, measured, or
collected (vital signs)
A: Assessment
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What the patient tells you
Summation of the diagnosis or the impression of
what’s wrong with the patient
P: Plan
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The steps the provider plans to take to treat the patient
Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.
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Digital Signature
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When a note is signed electronically, the
provider is representing that everything within
the note is correct
A notation of when it was signed and by
whom is shown below the signature line on
the saved note
Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.
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Questions?
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