EHR Demo Scenarios Family Practice
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1 EHR Demo Scenarios Family Practice #1 Walk-in Acute Patient 30 year old male, married patient, works in the maintenance department for Sugarbush Resort. Patients presents, bent over, complaining of acute back pain from shovelling snow on the job. Brings workman s comp papers with him. PMH: back problems Advil (when his back hurts) Multi-vitamin daily HPI: lower back pain, more severe on right side EHR should demonstrate: Review of medications and allergies Ascial release technique Referral to physical therapy New prescription Scheduling a return visit Creating an absence from work note
2 #2 Complex Patient 45 year old female, smoker, in the middle of a divorce, has two twenty-something unemployed children living with her. They are all on Mediciad. PMI: HTN, DM, Depression Lisinopril Lexapro Amitriptyline Metformin Avandia HCTZ Zoloft Klonopin HPI: Two-day history of chest pain, non-radiating Review of medications and allergies Referral to ED or cardiologist Ordering an ECG/viewing an ECG
3 #3 Non-conventional Patient Taking Herbal Remedies 35 year old male, single, works for Forest Service; new patient who thinks he may have Lyme disease. HPI: chronic fatigue, rash, headache, swollen stiff left hand Only takes herbal remedies Saw palmetto Hawthorn Holy basil Ginkgo Vit. E 1000mg Korean ginseng Vit. C 1000mg Calcium Magnesium Review of medications, allergies, drug interactions, amount of herbs consumed in one day Lab ordering Documentation of patient counseling/education Recommended treatment for new presentation of hypertension
4 #4 Established patient travelling to Africa (immunizations required) 40 year old male, works for International Corporation, travels often, recently returned from a trip to South America PMH: HTN, impotence, depression, OCD HPI: Diarrhea since returning from last trip Paxil Diovan Xanax Viagra Review of medications, allergies Lab ordering (parasite panel) Verification of immunization requirements before trip to Africa Documentation of patient counseling/education
5 #5 Well Woman Exam, Complex 55 year old female, divorced, 1 son, 2 grandchildren, works as a store cashier; no insurance; Ladies First for this exam; non-compliant with meds because she cannot afford them; does not understand process for applying for state insurance PMH: HTN, dyslipidemia, depression Medications Lipitor 20 mg Lexapro Lisinopril 5 mg Multi-vit HPI: Review of labs recently drawn one week prior to this visit Review of medications, allergies Lab results Documentation of patient counseling/education Breast exam Assistance with state insurance applications (link to webpage or pther info) Referral to social work or other assistance with living situation
6 # 6 Suboxone Patient (Opiate drug use treatment) 23 year old male, smoker, single, 6 months into the program, Medicaid, unemployed, weekly appt., counseling, AA meetings currently taking Suboxone. PMH: Opiate drug use, various street drugs, alcohol use, and depression. Suboxone Rozeram Lexapro HPI: C/O Anxiety regarding job search, problems regarding relationship with girl friend, hard to find transportation to get this office weekly for follow ups and script. 1. Obtain supervised urine sample and prepare it for shipment to out of state lab. 2. Review any current problems 3. Vital signs, ht and weight. 4. Physical assessment 5. New script 6. Return visit
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