Medical Assisting 5e EHR Exercises OLC

Patient A Profile

Chris Sykes is a 12 year old boy, born May 22, 2001. The patient is a white, English speaking, Caucasian.

Chris lives with his parents in Sherman, Texas. The patient has come to the clinic with his mother

because he is planning to start playing soccer and is required to obtain a pre-sports physical. The parent

is concerned about the family history of hypertension and heart disease and wants to make sure it is

safe for Chris to play. The patient is up to date on his immunizations.

Exercise 1A: Building a Patient’s Face Sheet

In this exercise you will add the patient’s past medical history and the family medical history to the face

sheet of the electronic chart.

1. Click one time on the patient Chris Sykes located on the office calendar.

2. In the Edit Appointment window click on the [Get Chart] button, seen in Figure A1.

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Medical Assisting 5e EHR Exercises OLC

Patient A Profile

Figure 1 Edit Appointment window.

3. In the patient’s electronic chart, click on the show chart/face sheet icon located to the right of the menu bar (illustrated in margin).

Show chart/face sheet icon (COMP: MARGINAL ILLUSTRATION)

4. In the face sheet window click on the [PMHX] navigation button (illustrated in margin).

PMHX button (COMP: MARGINAL ILLUSTRATION)

5. Type in the following information into Other PMHX window: Spider bite to left leg at age 5 approximate 3 cm in diameter swollen, red and itchy. Treatment

with hydrocortisone cream. Seen by other clinic.

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Medical Assisting 5e EHR Exercises OLC

Patient A Profile

Bicycle accident at age 9 with large bruised areas over both knees. Right forearm painful 8 out

of 10 pain scale with limited movement. X-ray showed no fracture. Treated with OTC pain

meds, rest, ice and elevation. Seen by other clinic.

Staff member: (Type your name here)

6. Because the patient was not seen in your clinic for the spider bite and the bike accident there is

no record of these diagnoses in your EHR system. You will need to add them. In the Dx field in

the upper right section of the screen type insect then click the search binoculars icon (illustrated

in margin). Select Insect Bite, Nonvenemous 919.4.

Dx field and search binoculars icon (COMP: MARGINAL ILLUSTRATION)

7. Once again, in the Dx field type bicycle and conduct a search. Select Bicycle Accident E826.

8. In the face sheet window click on the [FMHX] navigation button (illustrated in margin).

FMHX button (COMP: MARGINAL ILLUSTRATION)

9. Click in the Other FMHX window. Now in the Preferences window, click on the following items:

Note: After the selection of an item from the Preferences window, place the cursor after the

item before selecting the next entry. By placing the cursor after the selected word you are

telling the system where to place the next entry. You will need to type in the various ages as

noted. (COMP: SET NOTE IN BORDER)

Mother: Rheumatoid Arthritis. Diagnosed at age: 31

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Medical Assisting 5e EHR Exercises OLC

Patient A Profile

Father: Hypertension.

Maternal Grandmother: Breast Cancer. Died at Age: 57

Maternal Grandfather: Diabetes. Alive at age: 66

Paternal Grandmother: Bilateral Hip resurfacing. Alive at age: 55

Paternal Grandfather: CAD. Stent placement. Alive at age: 58

10. Click on the [Back] button located in the lower left corner of the face sheet window (illustrated

in margin). Notice the new information displayed in the patient’s face sheet portion of the

electronic chart, seen in Figure A2.

Back button (COMP: MARGINAL ILLUSTRATION)

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Medical Assisting 5e EHR Exercises OLC

Patient A Profile

Figure 2 PMHX and FMHX in face sheet of patient's chart.

11. Click on the File menu in the patient’s chart and select the submenu Print Face Sheet, seen in

Figure A3.

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Medical Assisting 5e EHR Exercises OLC

Patient A Profile

Figure 3 Print Face Sheet submenu.

12. Select the [Print] button in the Document Printing Options window. Print out your document.

Locate and circle your name in the PMHX section of the Face Sheet report. Turn in your

document to your instructor.

13. Close the patient’s chart by clicking the red ‘X’ in the upper right hand corner. Close the Edit

Appointment by clicking on the red ‘X’ in the upper right hand corner.

Note to Instructor: On the printed patient’s face sheet that the students turn in you will be

looking for the following:

1. The students name circled at the end of the PMHX section.

2. The Insect Bite and the Bicycle Accident diagnoses in the PMHX section.

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Medical Assisting 5e EHR Exercises OLC

Patient A Profile

3. The description of the Spider Bite and the Bike Accident in the PMHX section.

4. The family healthcare data in the FMHX section.

Exercise 2A: Building a Patient’s Office Visit Note

In this exercise you will add the chief complaints to an office visit note.

1. Repeat steps 1 and 2 in Exercise 1A.

2. In the patient’s chart, click on the ‘+’ sign to the left of the Encounter category in the upper right

section of the chart. Click on the Office Visit note dated 05/06/2013, as seen in Figure A4.

Figure 4 Locating Office Visit note in chart.

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Medical Assisting 5e EHR Exercises OLC

Patient A Profile

3. In the lower right section of the window, click on the [Edit] button to open the Office Visit note

(illustrated in margin).

Edit button in patient’s chart (COMP: MARGIN ILLUSTRATION)

4. The Office Visit (OV) screen will open and default to the Chief Complaint section. Select Pre-

sports physical from the pop-up text panel on the right side of the screen, as seen in Figure A5.

5. Skip a line in the lower Chief Complaint window and type the following:

Staff member: (Type your name here), also seen in Figure A5.

6. Click the [Done] button in the lower section of the screen. Click the [Save and Skip Billing]

button in the Save As window, as seen in Figure A6. Close the patient’s chart and close the Edit

Appointment window.

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Medical Assisting 5e EHR Exercises OLC

Patient A Profile

Figure 5 Selecting pop-up text in OV note.

Figure 6 Save and Skip Billing button.

Exercise 3A: Recording and Viewing Vitals

In this exercise you will record the patient’s vital signs in the OV note.

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Medical Assisting 5e EHR Exercises OLC

Patient A Profile

1. Repeat steps 1 through 3 in Exercise 2A

2. Click on the Vitals navigation tab on the right hand side of the screen (illustrated in margin).

Vitals navigation tab (COMP: MARGIN ILLUSTRATION)

3. Record the following vitals in the lower middle section:

Temperature: 98, Respiration: 20, Pulse: 88, Blood pressure: 110/68, Height: 4 ft 11 ins (convert

to inches), Weight: 100 lbs

4. Click on the show chart summary navigation tab (illustrated in margin). Scroll down through the

OV note and notice the recording of the vitals under the Objective section of the SOAP note,

seen in Figure A7. Notice that the BMI (Body Mass Index) is automatically calculated from the

height and weight of the patient.

5. Click the [Done] button in the lower section of the screen. Click the [Save and Skip Billing]

button in the Save As window. Close the patient’s chart and close the Edit Appointment window.

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Medical Assisting 5e EHR Exercises OLC

Patient A Profile

Show chart summary navigation tab (COMP: MARGIN ILLUSTRATION)

Figure 7 Vitals recorded in OV note.

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Medical Assisting 5e EHR Exercises OLC

Patient A Profile

Exercise 4A: Ordering Tests in an Office Visit Note

In this exercise you will order the following tests within the office visit note: UA (Urinalysis), CBC

(Complete Blood Count), and a CMP (Complete Metabolic Panel).

1. Repeat steps 1 through 3 in Exercise 2A.

2. In the Navigation panel to the far right, click on the Test navigation tab (illustrated in margin).

Test navigation tab (COMP: MARGIN ILLUSTRATION)

3. In the TEST field in the upper right panel type: UA and conduct a search by clicking on the

binoculars icon. Click on the displayed UA from the database which will move it down to the

lower Selected Tests window, as seen in Figure A8.

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Medical Assisting 5e EHR Exercises OLC

Patient A Profile

Figure 8 Ordering tests in the OV screen.

4. Repeat the previous step by searching for and selecting a CBC w/o Differential, and a CMP.

5. All three tests should now appear in the Selected Tests window. Now click on the [Ordered

Selected Tests] button in the lower right section of the screen (illustrated in margin). This will

send the tests into the OV note and place the tests in a pending area of the program where they

await entry of results.

Order selected tests button (COMP: MARGIN ILLUSTRATION)

6. Click the [Done] button in the lower section of the screen. Click the [Save and Skip Billing]

button in the Save As window. Close the patient’s chart and close the Edit Appointment window.

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Medical Assisting 5e EHR Exercises OLC

Patient A Profile

Exercise 5A: Administrating a Patient Instruction

In this exercise you will be selecting an appropriate patient education sheet to administer to the patient.

1. Repeat steps 1 through 3 in Exercise 2A.

2. Click on the Other Tx (Other Treatment) navigation tab (Illustrated in margin).

Other treatment navigation tab (COMP: MARGIN ILLUSTRATION)

3. From the Other Tx popup text panel select the phrase: Patient and parent had no questions to

send the text in the OV note, as seen in Figure A9.

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Medical Assisting 5e EHR Exercises OLC

Patient A Profile

Figure 9 Selecting popup text in Other Tx panel.

4. Click on the Tools menu and select the Patient Instructions submenu, seen in Figure A10.

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Medical Assisting 5e EHR Exercises OLC

Patient A Profile

Figure 10 Patient Instructions submenu in OV screen.

5. From the Choose Patient Instruction window, select the Preventative Healthcare Teens

instruction sheet.

6. At the bottom of the patient instruction type your name after Issuing Staff Member: as seen in

Figure A11.

Figure 11 Typing on to the patient instruction sheet.

7. Print out the document, circle your name, and turn into your instructor.

8. Notice in the Other Treatment note that the system automatically stamped the OV note with: Pt

Instr: Preventative Healthcare Teens given (seen in Figure A12) to document that you printed

the patient instruction for the patient.

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Medical Assisting 5e EHR Exercises OLC

Patient A Profile

Figure 12 Automatic administration of patient instruction note.9. Click on the [Print] button at the bottom of the OV screen (illustrated in margin) and print out

the OV note. Circle your name in the Subjective area at the top and turn in to your instructor.

Print button in OV screen (COMP: MARGIN ILLUSTRATION)

10. Click the [Done] button in the lower section of the screen. Click the [Save and Skip Billing]

button in the Save As window. Close the patient’s chart and close the Edit Appointment window.

Note to Instructor:

A. On the printed patient instruction sheet you will be looking for the following:

1. The student’s name circled at the bottom of the form.

B. On the printed patient’s office visit note that the students turn in you will be looking for

the following:

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Medical Assisting 5e EHR Exercises OLC

Patient A Profile

1. The patient’s chief complaint.

2. The student name circled in the Subjective area of the note.

3. The patient’s vitals under the Objective area of the note.

4. The three ordered tests under the Plan area of the note.

5. The recorded data that the patient and parent had no questions and that the patient

instruction sheet Preventative Healthcare Teens was given to the patient.

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