Mj and shrooms but no ivdu

Health Information Systems And The Electronic Health Record

earning Outcome: Examine required documentation and record structures

Students will utilize the Neehr Perfect EHR for this assignment. Prior to the assignment, students will need to complete some introductory activities in order to become familiar with the product.

It is recommended that students complete the following activities, however, you will not turn in these activities. They are useful in having you learn about how to navigate in the Neehr Perfect EHR. Completing these activities will make the assignment flow more easily.

a. Neehr Perfect Scavenger Hunts Levels I - III

-Level I

-Level II

-Level III

b. Neehr Perfect Activity: Data Entry

c. Neehr Perfect Activity: Communication in the EHR

Assignment 1: : Neehr Perfect: EHR Documentation Evaluation

Once these are completed, you should have the tools to complete the EHR Documentation Evaluation.

Enter your answers directly on the sheet. Save the document with the following naming convention: neehr perfect 1-lastname.first name

Neehr Perfect Activity: Communication Within the EHR
Overview
This activity is designed for the beginning EHR student user. The focus of the activity is how clear documentation in an EHR can facilitate communication among the healthcare team. The student will look at diagnoses and problems documented in a patient chart and the use of approved, and unapproved, abbreviations.

Prerequisites
1. Completion of Scavenger Hunts I - III

Student instructions

1. If you have questions about this activity, please contact your instructor for assistance.

2. Document your answers directly on this document as you complete the activity. When you are finished, save this document and upload it to your Learning Management System (LMS). If you have any questions about submitting your work to your LMS, please contact your instructor.

3. Screen displays are provided as a guide and some data (e.g. dates and times) may vary.

Additional resources

1. You may use any of the following resources to complete this activity:

a. The EHR: The Lexicon search on the Problems tab.

b. Websites.

c. Your textbooks.

Objectives

1. Demonstrate ability to locate necessary data from a patient chart.

2. Apply diagnosis codes according to current guidelines.

3. Identify errors in documentation within a patient chart.

Glossary

ICD-10 - The 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. ICD-10s are very detailed in their descriptions, compared to the ICD-9s that are no longer in use.

Problem – A current or a historical health care problem. Sometimes called a diagnosis or a “complaint.”

The activity

Patient problems: communicating with the healthcare team

For patients with a 3 to 5-day hospital stay, a study revealed that an average of 30.8 clinicians could access the electronic chart, including 10.2 nurses, 1.4 attending physicians, 2.3 residents, and 5.4 physician assistants (Vawdrey et al, 2011). With those numbers alone, the importance of accurate and timely documentation in the EHR is imperative.

A problem list can summarize patient medical information, such as a patient’s major diagnoses, symptoms, past medical and/or surgical history, and recurrent complaints. This problem list can be seen by those involved in the patient’s care allowing for communication within the patient’s medical record. When documented correctly, this can ultimately lead to continuity of care, improved patient safety, and a thorough interdisciplinary approach. There are many times that healthcare team members never see one another, and the only way to communicate to others caring for the same patient is through the documentation in the patient’s medical record.

Go to the chart of Warren Olson. Notice that his active problems are listed as ICD-9 codes. In this activity, you will be updating all of the current ICD-9s to ICD-10s. Notice how the ICD-10 terms are more specific and there is a different code for left, right, and so on.

1. To update the Problems, you will be filling in the blanks in the table below. You may use any of the following resources to complete the table.

(You may be prompted to choose an Encounter Provider. Choose your instructor and click OK).

· The EHR: On the Problems tab click on New Problem. You can enter the ICD-10 code or the diagnosis. Click on Search. Once you have your answer click on Cancel to enter a new diagnosis or code. DO NOT CLICK OK AND DO NOT SAVE ANY PROBLEMS TO THIS CHART. You will not be documenting in Warren Olson’s chart. You will be entering your answers in the table below.

· Websites.

· Your textbooks.

Current diagnosis

ICD-9

Updated diagnosis term

ICD-10

List your resource

Coronary Artery Disease

414.9

I25.9

Carotid Stenosis

799.9

Occlusion and stenosis of unspecified carotid artery

Cerebrovascular Accident

436.0

Occlusion and stenosis of right posterior cerebral artery

Peripheral Vascular Disease, Unspecified

443.9

I73.9

Hypertension

401.9

I10

Hearing Loss

389.9

Unspecified hearing loss, bilateral

Syncope

780.2

Syncope and collapse

2. Looking at the Problems tab in Mr. Olson’s chart, do you feel this is enough information to accurately explain why the he was admitted to the hospital? Does it present a clear enough picture to the healthcare team? Explain why or why not?

3. Mr. Olson also has symptoms that are documented in the admission notes that can be used to communicate presenting complaints and immediate concerns on the Problems tab. When a patient arrives to the emergency room, and before a diagnosis is entered, there are symptoms that tell the healthcare team what is going on. For example, “The patient came in complaining of being dizzy and nauseated.” These symptoms lead to assessments and tests, which in turn produce a diagnosis.

Complete the table below. This information was gathered from the MEDIC: ADMIT NOTE documented when the patient first arrived at the hospital. Using the same resources from question #1, locate the medical term, or problem, that would be coded with an ICD-10 code.

Symptom

Medical term (or Problem)

(Use the term associated with the ICD-10 code)

ICD-10 code

List your resource

Weakness

Muscle weakness (generalized)

Slurred speech

Lightheaded

Dizziness and giddiness

SOB (shortness of breath)

4. Should Mr. Olson’s symptoms have been included on the Problems tab? Explain why or why not?

Errors in communication

A study at a large urban hospital found that while pediatricians were able to understand 56-94% of the abbreviations used, physicians from other fields understood only 31-63% of those same abbreviations, highlighting the ambiguous nature of many abbreviations. Another study looked at a selection of abbreviations from recent hospital admissions and asked different members of a multidisciplinary care team to decipher them. They found that the average correct response rate was only 43%, with specific abbreviations better known by the professionals who used them the most. A third study in Australia that looked at error-prone abbreviations in medication orders found that of the 8,296 medication orders, 1,162 error-prone abbreviations were found, with an average of 2.4 per patient (Rodwin, B. 2013). Not only do abbreviations make it difficult for healthcare team members to understand fully what is occurring with their patient, but abbreviations are a major safety concern for the patient.

5. Go to the Notes tab of Mr. Olson’s chart and look at the following notes, MEDIC: CONSULTATION REPORT and the MEDIC: ADMIT NOTE. Read the notes. Notice the abbreviations and use of symbols. Using online resources or your textbook, decipher the following. Write your answers in the table below.

Abbreviation

What it means

List your resource

“s/p 3V CABG”

“s/p L CEA”

“SVG->OM”

“MJ and

shrooms but no IVDU”

“Abd soft, NT/ND”

“check TTE to eval LV fxn and valvular dz”

“HEAD: NCAT”

“sig b/l weakness X 4 limbs LE more pronounced”

6. Having completed the table in #5, answer the following question. Do you feel that healthcare providers should not use abbreviations when documenting, or should they be limited on the abbreviations they can use, such as a standardized abbreviations list? Explain your answer, and provide references if any were used.

Submit your work

When you finish the activity, you will submit this Word document with your answers to your instructor through your Learning Management System (LMS). If you have questions about submitting your work, please contact your instructor.

References

Rodwin, B. (2013). Why you should think twice about using medical abbreviations. Clinical Correlations. Retrieved from http://www.clinicalcorrelations.org/?p=6304

Vawdrey, D. K., Wilcox, L. G., Collins, S., Feiner, S., Mamykina, O., Stein, D. M., Stetson, P. D. (2011). Awareness of the Care Team in Electronic Health Records. Applied Clinical Informatics, 2(4), 395–405. http://doi.org/10.4338/ACI-2011-05-RA-0034

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Neehr Perfect Activity: Communication Within the EHR v4

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