EMR Tutorial Electronic Medical Records are currently used at two HOP clinic sites, Eliza Shirley and Salvation Army. By transitioning to EMR, we hope to improve patient care and help prepare pre-clinical medical students for use of EMR during rotations and beyond. The platform that we use is called Practice Fusion. There are six fields in the EMR that you should be filling out: Chief Complaint, Vitals, Allergies, Past Medical History, Subjective (aka History of Present Illness), and Objective (aka Physical Exam). Helpful Tips: 1) Feel free to take notes as you progress through the patient interview. That is, do not worry about entering all of the information into the correct fields during the interview because you will have time to transfer this information into the correct fields once the interview is over. You can take notes in the Subjective section of the EMR chart, or you can take notes by hand! Just be sure to transfer all of the information into the correct fields after you are done interviewing the patient. 2) You may find it helpful to use Print Preview Mode when presenting to the physician because you won t have to do as much scrolling through the chart. See Section VIII: Finishing Up 3) Depending on the clinic, you might be asked to document the physical exam findings while in the room with the physician and the patient. Do not worry about this too much because the final exam findings will be reviewed by the attending physician. Just try your best! 5) Be sure to click Save in the upper right of the screen!
I. Getting Started a) Make sure you enter the attending physician s name in the SEEN BY drop down menu. Do not enter your name here. b) Make sure that the correct clinic has been entered in the FACILITY drop down menu
II. Chief Complaint Click Record to record the chief complaint. Pretty straight forward. III. Vitals Record the following vital signs: BP, pulse, respiratory rate, weight, and temperature (when appropriate). Then click Done.
IV. Allergies a) Click Record next to the Allergies section. b) The screen on the right will pop up and you will be able to enter detailed allergy information. You must use the search field in order to find the allergy. Note that you can add Drug, Food, and Environmental Allergies. Then Click Done. * Note: If you are having trouble finding the right allergy, you can manually enter allergies in the Past Medical History section (see below)
V. Past Medical History *Note: This is also where you will enter Family Medical History and Social History Click Record to begin. a) Document surgeries in the Major Events section b) Document the patient s Ongoing medical Problems c). Document the patient s Family Health history d) Document the patient s Social history * Note: you can enter allergies under Allergies (free text) if you aren t able to find them in the Allergies section above
VI. Subjective (aka History of Present Illness) a) The subjective section is where you are going to record the History of Present Illness. Click Edit/Record to begin.
b) After clicking Edit, a window will pop up in the middle of the screen that contains templates. You must click on the HOP_SUBJ_ADULT&PEDS template to begin recording the HPI. Click on this template c) Then click on the bolded text Patient interviewed by You can now start recording the HPI d) Be sure to record your name! Then record the patient s HPI under the header History of Present Illness header
VII. Objective (aka Physical Exam) a) The objective section is where you are going to record the physical exam. Click Record to begin b) Again, a screen will pop up that contains templates. This time click on either HOP_OBJ_ADULT for adults or HOP_OBJ_PEDS for children. Click on the appropriate template to begin.
c) After clicking on the appropriate template, this screen will appear (encircled in red). Here you can fill in the physical exam findings. Click on the relevant system to begin recording the physical exam findings. For example, for a patient with lower back pain, you would probably want to click on Musculoskeltal and/or Extremities, and then fill in the findings. Just try your best!
VIII. Finishing Up: Using Print Preview Mode and Printing the Note * Viewing the patient s chart in print preview mode makes it easier to present your patient to the physician because you won t have to scroll up and down the chart. a) To begin, click on the Actions drop down tab in the upper right corner of the screen b) then select Print encounter This is how the chart will look in print preview mode: