EHR: Scavenger Hunt I

Transcription

1 EHR: Scavenger Hunt I

2 Metadata Author: Kay Folk Date Submitted: 03/21/07 Editor: Kathie Owens & Sandra Kersten Competency Domain(s) Health record data collection tools Competency Subdomain(s) IA. Health Data Structure, Content and Standards Competency Task/Skill(s) AS IA1. Collect and maintain health data (such as data elements, data sets and databases). Knowledge Cluster Content(s) Competency Level Associate, Baccalaureate, or Both? Suggested Course Usage V-Lab Technology(ies) Used Estimated Completion Time (in 15-minute intervals) Necessary Prerequisite Knowledge Data Requirements IA2. Conduct analysis to ensure that documentation in the health record supports the diagnosis and reflects the patient s progress, clinical findings and discharge status. N/A Both Fundamentals of HIM EHR Application 45 to 60 Minutes Basic Understanding of EHR Loading Citrix Records in EHR Revised: 8/15/2009 2

3 Objectives: After completing this activity, you will be able to... Conduct a patient lookup in the Cerner Powerchart EHR Navigate the various screens in Powerchart Change data views in Powerchart Find and review patient demographics Find and review a patient s diagnosis Revised: 8/15/2009 3

4 Introduction As you embark on a career as an HIM professional, it is imperative that you understand how information is stored in EHR applications. This exercise will introduce you to basic navigation and features in the ATHENS/Cerner EHR. Warning: Before starting this activity you must download Citrix. Refer to the EHR Student Guide provided to you by your instructor for additional instructions. You must also have your Virtual Lab student registration confirmed in the Web Registration System. If you have not done that, please see your instructor for additional assistance. Revised: 8/15/2009 4

5 Lab Activity Task # Task Detailed Steps 1 Logging into the EHR If you have downloaded Citrix to your computer, log into the Cerner EHR to get started: 1. Go to your pc internet browser and type the URL: 2. Type the username: SCHLMN 3. Type the password: ATHENS*5 At the next screen: 4. Double-click on Power Chart 5. Type your 7-digit AHIMA member ID 6. Type your password 2 Getting Started in the EHR Note: If you ve logged into the EHR before, your password is one that you ve created for yourself the first time you logged in. If you re logging in for the first time, your password is the same as your 7-digit ID. You ll need to create your own password when you get a successful login. In this exercise you will identify patients in the EHR by using the Patient Search. Note: all patients with last names beginning with Vlabxx (e.g., Vlabfemale,Ortho; Vlabmale,Vasc) are shared patients. These records are based on actual hospital cases, and intended for use by all schools. Never enter any data on these patients, or the program will risk losing Vlab privileges. To conduct a Patient Search: Click the Patient at the top of the toolbar. Then click on Search, OR Click on the binoculars icon on the top right side of the menu bar. Patient Search Exercises and Questions: 1. Type or Enter br in the name search box 2. Click the search button at the bottom of the screen. 3. What is the first name on the list? 4. What is the last name on the list? 5. Do they all begin with br? (Record your answer on the worksheet). 6. Refine your search further by adding gender to the search. Choose female in the gender box, then click the Search button again. Revised: 8/15/2009 5

6 7. What happens to the list? Does the number of found entries increase or decrease? 8. Now, SEARCH Jayna Broadston then click OK at the bottom right corner of the Patient Search screen. 9. Next click on the Left side of the Screen Under Menu on Patient Info. 10. What is Jayna s religion?. 11. Close Jayna s chart by clicking X on the Patient Tab with her name on it. Caution: You may have many patient tabs open at one time, however, you must be very careful that you are working in the correct patient. It is very easy to Alt+Tab and land in the wrong patient account. More current versions of Powerchart automatically close one patient when another is opened. This is a patient safety improvement. 12. Begin a new patient search Patient>Search Then enter DOB 08/03/1931 in the birth date search field -> click Search. Write down the name of the patient displayed (if more than one, select one and write in the patient name you select)?. 13. Click on the Patient Info button. What is the Marital Status? Next Search: Search for patient Vlabfemale,ORTHO Enter vlabf, ortho2. Note: When searching by patient name in most databases, entering a partial name is recommended. If the user misspells the name, or mistypes a letter, the search may not produce any matches. Enter the first three or four letters of each name, using the comma to separate the first and last names. 15. Highlight the record for Vlabfemale, Ortho2 and click ok Revised: 8/15/2009 6

7 16. Which chart tab does the record open to? - (This would be called the default view). 17. The green/yellow banner bar at the top shows ***Allergies*** Which indicates the patient is allergic to something. Looking at the screen to the left of the page, name four things the patient is allergic to. a. b. c. d. 18. From the information on this screen, does it appear that the patient has an Advance Directive? Yes or No. Now that you ve demonstrated how to search for patients in the EHR, let s start reviewing the patient s record in the next step. 3 Reviewing Patient Diagnosis Part I While at the current page of the application, look at the table at the bottom right hand corner of the screen; it gives a snapshot of data and documentation on the patient. Switch views by selecting one of the radio buttons in the middle of the page. Depending on your clinical role or preference, you may alter the way that you view patient diagnostic data. 4 Reviewing Patient Diagnosis Part II Under Menus, go to the Results Review button. The Key Results tab should be open. Look familiar? This is the same data that appeared in the table at the bottom of the Chart Summary screen you were just on. Flowsheets are powerful tools but can be overwhelming in the amount of data they present. So EHR s provide the user with tools to sort and filter the data based on the needs of the user. Let s try a couple things: 1. Go to the Flowsheet drop-down menu 2. Select Physician Office/Clinic View. Revised: 8/15/2009 7

8 3. What happens to the Navigator panel on the left?. 4. Go back to the All Results Flowsheet view in the Flowsheet dropdown menu. Do you see a blue box labeled Neurological in the Navigator panel on the left? 5. To help answer this question, return to the Physician Office/Clinic View in the Flowsheet drop down menu. Are you able to click on the Neurological button? Try this. 6. Why do you think neurological documentation is not included in the physician clinician view? Here s a freebie: It only displays relevant documentation for that physician specialty, although other results are available to the physician. 7. Do you remember what happened when you clicked on the Navigator button labeled Neurological? So what would be a quick way to get to the Diagnostic Radiology results?. 8. Once you do this, then double click on the cell titled General Radiography Report 9:46pm (to the right of the page). a. What type of x-ray is displayed? b. Was this x-ray done pre or postop? c. What part of the anatomy was being x-rayed? 9. Click ok to close this window. 5 Reviewing Vitals, Part I Click on Results View and then on the Vitals View tab. Select the tab and explain briefly what does this tab show/do? 1. Reviewing vitals is not on the quiz, but take some time to observe the different data on the various tabs. Just as there are ways to sort and filter large amounts of varied data, there are also ways to sort and view specific sets of data such as vitals. 2. Right mouse click on the dark blue bar above the Navigator and Vitals View and you will see an option to Change Search Criteria. 3. Highlight and left mouse click. 4. Which result option is the default (selected radio button)?. Revised: 8/15/2009 8

9 5. If a doctor was looking for blood pressure values posted in the first 10 days since admission. What option would she select? Change search criteria to Clinical Range and set the dates to 4/19/2006 4/29/ Suppose you want to trend the BP results during that time. To do this, you need a graph. 7. Left click the little gray box preceding the systolic blood pressure and the diastolic blood pressure the box will now appear checked. 8. Select the graph icon at the top of the screen in the Results Review -> First icon from the end. 9. What happens how many diastolic values do you have to graph? 10. How many systolic values are there? 11. What happens when the two graphs are combined? (click Combine). 12. Can you think of a time when it would be helpful to be able to compare two values together? Don t panic, This is not on the quiz. Just give it some thought 13. Click close to close graph and return to the chart. 6 Reviewing Reports To review reports on a patient in the EHR, click on the Reports button under Menu. 1. What do you see?. 2. Look at the dark blue bar just above the blank view panel, what date range appears here?. Note: This is the default date range set for retrieving reports stored on this patient. Revised: 8/15/2009 9

10 3. Based on what you just did in exercise #4 above, what would you do here to get to the reports in the database on this patient?. Recommendation: Select radio buttons for Documents for Selected Encounter AND All Documents 4. Before proceeding, note the five (5) radio buttons at the bottom on the navigator panel. Select each one and note what you see: Note: By type is selected. 5 Reviewing Report Type a. By type b. By status c. By date d. Performed by e. By encounter Now, reset the report navigation to by type, and then double click the Clinical Documents folder. What are the first four (4) document type folders appear a. b. c. d. Do the same for the Radiology folder and document what you see.. 8 Reviewing Report Info Now open the Surgical Documentation sub-folder (under Clinical Documents). 1. What two types of surgical documentation do you see? a. b. 2. What was the post operative diagnosis?. 3. The yellow dot in the middle of the pink box beside the report name in the Navigator panel indicates that it is the document that is currently displayed. Reviewing Report Info (cont) Let s continue reviewing patient vitals in the EHR application. To do this Right click in the Navigator panel and determine whether documents are displayed in chronological or reverse chronological order.. Revised: 8/15/

11 2. Finally, why are the boxes preceding each report colored and what do the colors mean? (read below) To find out Right click in the Navigator panel again and select color legend. Authenticated/verified means the report has been reviewed and electronically signed by the author and stored in the database as final. 4. Now, what color box would a document have that still requires author signature (Unauthenticated)? 5. What is the clinical significance/importance of flagging the status of reports? 10 Exiting Cerner EHR Great job! Now it s time to close the chart and do a clean exit of the system. 1. Close the chart go to Chart, top, at the left option of the screen click, scroll down to close chart and click. Note: this closes the chart you ve been working on but not the EHR application. 2. Close EHR Click the Exit icon on the tool bar. 3. Exit Citrix the Cerner Citrix portal is still running. It may come to the screen automatically, if not, then select welcome to CernerWorks from the applications status bar at the bottom of your screen. 4. At this point it is safe to X-out of (close) the screen Thank You! 1 Revised: 8/15/