Neehr Perfect Activity: Registering a Patient And

Crystal J Evans

Week 3 Assignment 2: NEEHR Perfect EHR Activity - Registering Patients and Adding Orders

Neehr Perfect Activity: Registering a Patient and

Adding Orders Part I

Overview

This activity is intended for the beginning and intermediate EHR student user. In this activity, students register a patient in the EHR using Student Tools and then add orders for the patient. The student will then answer critical thinking questions. This chart will be used again for Part II of this skill in Neehr Perfect Activity: Adding Orders Part II.

Prerequisites

Completion of Neehr Perfect Scavenger Hunts I - III
Completion of Neehr Perfect Activity: Data Entry
Completion of Neehr Perfect Activity: Using the Tools and Resources in Neehr Perfect (optional)
Review the Quick Guide to Using Student Tools (found under Help > Guides on neehrperfect.com)

Student instructions

If you have questions about this activity, please contact your instructor for assistance.
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.
Screen displays are provided as a guide and some data (e.g. dates and times) may vary.

Additional resources

You may use the following links to assist in completing this activity.
Taber’s Online medical dictionary,
Banner Health, Title: Documentation Requirements for the Medical Record,

Objectives

Apply data entry skills to create a new patient chart.
Demonstrate timely, complete and accurate entry of health care data.
Identify advantages and disadvantages to computerized order entry.
Define healthcare terms and acronyms related to computerized order entry.

The activity

Entering data into a patient’s health record must be accurate, unbiased, completed in a timely manner, and be entered in a way that the data can easily be extracted. To accomplish this,many steps are taken by a facility and the individual entering the data in the EHR. The list below outlines some of the steps taken. This list is not all inclusive.

Use of structured data fields (i.e. check boxes, drop-down menus).
Use of templated notes that have been customized to fit the specific needs of the facility and department.
Avoid use of a copy and paste feature.
Spell check and proofing of free-text fields.
Correct identification of the person to match their medical record.
Use of computerized physician order entry.
Implementation of policy and procedure to reduce risk of errors and increase patient safety.
Employment of staff that have the appropriate level of education and experience to fit their level of responsibilities.
Proper training of staff that will be performing data entry.

Now, imagine you are working in a hospital emergency department. Today is your first day at work without your preceptor. A child has just arrived at the unit. You are handed paper orders from the nurse and asked to create a new patient chart and enter the orders in the EHR. Use the information below to create the chartand enter the orders.

Registering a patient

Log in to the EHR. At the Patient Selection Screen, choose and open your portfolio chart (the chart named with your first and last name and the word "Portfolio").
With your portfolio chart open,locate the Tools menuat the top of the screen and selectTools > Student Tools.
Use your Username and Password to sign in to Student Tools. You are required to do this again for security purposes. Remember that you are using a real EHR and HIPPA and Confidentiality apply.
Click on Add Patient.

Use the following patient information to fill in the required fields (every field that has an asterisk* is required). Click Save when you are finished.

Patient information:

Name:Use your own last name as the patient’s last name. Make the first name Orderand the middle name your own first name (Your last name, Order Your first name – for example, if your name was Bobby Jones: Jones,Order Bobby)
DOB: 8/22/2009
Marital Status: Never married
Division: Your school’s “Common Division”
Sex: Male
Status: Not Employed
Address: 8745 Freedom Way, Chicago, Illinois 65423
Home Phone: 874-555-4562

Click Save.You do not need to add Employment Information.

Click on Emergency Info and enter the following and then click Save:

Name: Mother,Wanda
Home Phone: 874-555-4562

Click on Admission Info and add the following info and then click Save:

Location: Emergency
Admission Date: Enter today’s date and time at 0:00
Discharge: Leave Blank

Entering orders

Return to the EHR by selecting the CPRS Icon or on your taskbar at the bottom of your screen.

Once in the EHR, go to the menu at the top of the chart and choose File > Select New Patient. When the Patient Selection Screen appears, start typing your last name and the chart you just created (Your last name, Order) should appear at the top. Double click or highlight and click OK to open.
Click on the Orders tab at the bottom of the chart. Follow the directions to enter the orders below. Use the current date and time when entering the order.

Order / Directions for order entry
1. Admit / Select A/D/T on the left panel. You will then see a pop-up box asking for the Provider and Location. Select your instructor as the Encounter Provider. Then click on the Hospital Admissions tab and select the Emergency entry displayed below and click OK.
Click on Admit Patient.
Treating Specialty: Medical Observation
Attending/Primary Physician: Choose your Instructor from drop-down menu
Unit: Pedsunit
Leave Date to Admit as today.
Leave Expected Date of Discharge blank.
Click on Accept Order.
Admitting Dx: Dehydration
Click on Accept Order.
Condition: Stable
Allergies: None. Click the No known allergies box. Then click OK and OK again. Then choose DONE.
2. Obtain weight / For this order and the remaining orders below, select Patient Care on the left panel. Then select Text Only Order and type in the order (in this case “Obtain weight”). The Start Date/Time will be NOW and you don’t need to enter a Stop Date/Time. Then click Accept Order. Repeat these steps for the orders below.
3. Initiate Oral Rehydration Solution 50mL/kg over 4 hours / Repeat steps from above to enter this order.
4. Strict I and O / Repeat steps from above to enter this order.
5. Vital signs Q4H / Repeat steps from above to enter this order.
6. Complete a neuro checkQ4H / Repeat steps from above to enter this order.Then click Quit and then Done.

When you are done, selectFile > Refresh Patient Information. You will be prompted to select the type of signature. Select Signed on Chart and then OK. Then enter your username and select OK to sign off the orders.

Critical thinking questions

For this activity, you entered the orders in a free-text format. You may have noticed in the Patient Care Orders window that there were “pre-defined” Patient Care Orders listed. For example, Neuro Check:

Identify one advantage and one disadvantage to using the free text order entry compared to using the “pre-defined” order entry.

One advantage of using free text order enter compared to predefined is that the free text allows you to put in exactly what the MD orders. The Disadvantage is that you may use the predefined but not at the correct orders such as how many or how much the MD wants. This can lead to medical mistakes.

Using your textbook or the Internet, define the following termsand acronyms. List your resources.

Computerized Physician Order Entry (CPOE): when medical professional enters orders electronically versus the use of paper enter. This helps reduce errors due to bad handwriting or transcription errors.
A/D/T: - Admissions/Discharges/Transfers
Strict I and O: Strict monitoring of patient’s input and output
Q4H:every four hours
Pads unit:Unit in hospital this is equipped to care for pediatric patient’s needs.

In this activity, you were “handed paper orders” to interpret and place in the patient chart. Explain why having the physician enter the orders directly into the EHR would be an advantage, or a better process, than having you enter the orders.

The Physician know exactly what they want to order and how much and when they want something done. It is easier than paper writing in which you must try to read a dr’s bad handwriting and having to call him to verify orders you don’t understand or have a question about. With the use of the EHR the physician can enter orders and use the drop-down menus to make selections and have a record or the patient to give information into what the patient needs and already had done. The physician can check allergies and patient past records to see what needs to be done for the patient.

What is computerized physician order entry (CPOE)? - Definition from WhatIs.com. (n.d.). Retrieved May 27, 2017, from

Crystal J Evans

Week 3 Assignment 2: NEEHR Perfect EHR Activity - Registering Patients and Adding Orders

Crystal J Evans

Week 3 Assignment 2: NEEHR Perfect EHR Activity - Registering Patients and Adding Orders

Submit your work

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.