1. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Chapter 6 Clinical Use of the Electronic Health Record

2. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Clinical Use of the Electronic Health Record 1. Describe the benefits of documentation in the electronic health record (EHR). 2. Explain the role of speech recognition software in medical documentation, and describe the benefits of the technology. 3. List the components of the medical, surgical, family, and social history. 4. Explain how the chief complaint and history of the present illness relate to each another. 5. Enter allergies, medications, and intolerances into an EHR. 6. Discuss what components of a patient's vaccination history should be included in the chart. 7. Describe how to record vital signs and anthropometric measurements in the EHR. 8. Outline the process many physicians use for constructing a progress note. 2 Lesson 6.1

3. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Documentation in the Electronic Health Record  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 3

4. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Voice Recognition  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 4

5. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Documenting Remote Patient- Provider Encounters  Telephone documentation  Med refills, sick calls, patient treatment questions  E-visits  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 5

6. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Clinical Documentation in the Patient Record  In SimChart for the Medical Office (SCMO), the patient visit is called an encounter  Three types of encounters:  Comprehensive Visit  Office Visit  Phone Consultation 6

7. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Allergies  Document allergies:  Environmental  Seasonal  Contact  Food  Verify at every visit  Document corresponding reactions 7

8. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Documenting Patient History  Medical and surgical history  Family history  Social history 8

9. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Chief Complaint  CC or cc  The patient’s main reason for seeking medical care  Use the Record drop-down box to add new CC 9

10. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. HPI  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 10

11. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Pain Scale  “Fifth vital sign”  Describes quality of pain on a scale of 1-10  Wong-Baker scale for children 11

12. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Problem List  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 12

13. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Medications  Patients may be on medications from more than one provider  Vital to keep the medication record current  Record reasons for discontinuing medications 13

14. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Immunization History  Document both childhood and adult immunizations  EHR is a good tool for tracking immunization history, and when new immunizations are due 14

15. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Immunization Documentation  Name of immunization  Name of person administering the immunization  Date given  Location of injection  Category  Manufacturer  Type  Expiration date  Lot number 15

16. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Using the EHR for Patient Education  The EHR contains health data collected over a long time, allowing the attentive clinician to identify long- term trends that indicate elevated disease risk  Guidelines for effective patient education:  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 16

17. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Vital Signs  Recorded at the start of every visit  Anthropometric measurements  Height, weight, BMI, head circumference  Vital signs: temperature, B/P, pulse, and respirations 17

18. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. The Progress Note  S: Subjective  What the patient tells you  O: Objective  Information that can be observed, measured, or collected (vital signs)  A: Assessment  Summation of the diagnosis or the impression of what’s wrong with the patient  P: Plan  The steps the provider plans to take to treat the patient 18

19. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Digital Signature  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 19

20. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Questions? 20