Go! Patient Chart Submission Template

Your Contact Information

Your Name:

Your Position and Department:

Your School:

Your email:

The best phone number to reach you at if we have a question:

Before you choose to write a patient chart, it is important to examine the potential educational merits of the chart. Ask yourself the following questions:

What Learning Objectives could be met with use of this chart in a homework or skills assignment?

Identify core knowledge, physical skills, or important decision-making experiences the student can achieve through the use of this chart.

  • What do you want the student to complete with this patient chart?
  • What do you want the student to think about through this patient chart?
  • What do you expect of the student in relationship to this patient chart?

How could the use of this chart enhance a simulation? What Learning Objectives could be met with use of this chart in an interactive simulation setting?

  • What data do you need to provide in the chart for base information about this patient?
  • What skills or assessments should be done with this patient?
  • What unexpected events or common clinical situations could be presented via the use of this patient?

Charts can be simple or complex, long or short. All Neehr Perfect EHR patient charts contain some or all of the following types of information. Please provide all patient chart data in the fields below.

Patient Chart Data

OVERVIEW & EDUCATIONAL DATA

Patient chart summary/synopsis: (Freetext description of the patient scenario.)

Suggested uses: (List some ideas for curricular use of this chart. E.g. Particular skills practice, certain type of medication administration, physical examination skills, pathophysiology, etc.)

DEMOGRAPHIC DATA

Demographics/Registration information:

Name:

Sex:

Date of Birth (only month and day are needed):

Age:

Medical Record Number:

Marital Status:

Street Address:

City:

State:

Zip:

Home Phone:

Employment Status:

Parent or Guardian Information:

Guarantor Information:

Insurance:

Encounter (i.e. Visit or Admission) Data

Inpatient or Outpatient:

Location- choose from:

  • Central Clinic
  • General Hospital
  • Shoreline Birth Center
  • Hillside Pediatric Hospital
  • General Hospital ER
  • Highlands Long Term Care
  • Valley View Therapy Center

Description:

HEALTH DATA

Alerts Data(e.g. Allergies, Fall Risk, Isolation)

Type (choose from Advance Directive, Adverse Reaction/Allergy, Crisis Note, or Clinical Warning):

Status (choose from Active or Inactive):

Subject (May be Free text or marked as NKA):

Signs/Symptoms:

Notes and/or Attachments (Optional. Attachments can be in gif, jpg or png format only):

Problems Data (e.g.active, resolved, chronic or acute problems)

Date of onset:

Problem (name of problem with ICD code, if applicable):

Status (choose from Active, Inactive, Resolved, Removed):

Immediacy (choose from Acute, Chronic, Unknown, S/P):

Priority (freetext to be used if applicable, e.g. Presenting, Admitting, Primary, etc.):

Vitals Data (Include values and times. Repeat as many times as needed.)

Date/Time:

TPR B/P O2 (include qualifiers, if desired):

Pain (types include numerical, CRIES, Nonverbal and Wong Baker):

Growth & Development (weight, height/length, head circumference, if applicable):

Intake & Output (include method and description, if desired):

Orders Tab: (Include all details below. Repeat as many times as needed.)

Date/Time:

Order Category (Available categories include Scheduled Med, Prescription, Laboratory, Diagnostics, Consults, Procedures, Location, Supplies/Devices, Care, Screening/Measurements, Therapy):

Order Item: (This is the name of the medication, lab, diagnostic test, etc. being ordered):

Quantity (if applicable):

Route (if applicable):

Frequency:

Order Details (This is a longer text box that can contain freetext description or instructions for order under when applicable):

Status (Most often the order status is “Active,” but an order can also be written as “On Hold,” “Flagged,” “Pending,” “Expired,” “Completed,” or “Discontinued”):

Meds Tab:

Orders of the type “Scheduled Meds” will automatically show up on the Meds Tab. Active Scheduled Meds are the only types of orders that can be administered using the barcoded eMAR.

Notes Tab: (Include all details below. Repeat as many times as needed.)

Hint: ** Most charts should contain a History & Physical or Admission Assessment and at least one Progress Report to help tell the clinical story.

Note Title: (You may choose a title for your note. Common note titles examples are, “Progress Note,” “H&P,” “XRay Report,” “Fall Risk Assessment,” “Teaching Plan,” etc.)

Date/Time:

Text of Note:

Images for note (if applicable):

Care Plans Tab: (Care Plans can be partial or complete. They help direct the student and focus their patient care.)

Date/Time:

Care Plan Title/Nursing Diagnosis:

Related Medical Diagnosis:

Goal:

Interventions & Evaluations:

Outcomes:

Labs Tab:

Date/Time / Lab / Results / Date/Time / Lab / Results
ABGs / ABGs
PaO2 / PaO2
PaCO2 / PaCO2
pH / pH
SaO2 / SaO2
HCO3 / HCO3
BMP / BMP
BUN / BUN
CO2 / CO2
Creatinine / Creatinine
Glucose / Glucose
Serum chloride / Serum chloride
Serum potassium / Serum potassium
Serum sodium / Serum sodium
Complete Metabolic Panel / Complete Metabolic Panel
Glucose, Serum / Glucose, Serum
BUN / BUN
Creatinine, Serum / Creatinine, Serum
BUN/Creatinine Ratio / BUN/Creatinine Ratio
eGFR if NonAfrican American / eGFR if NonAfrican American
eGFR if African American / eGFR if African American
Sodium, Serum / Sodium, Serum
Potassium, Serum / Potassium, Serum
Chloride, Serum / Chloride, Serum
Carbon Dioxide, Total / Carbon Dioxide, Total
Calcium, Serum / Calcium, Serum
Albumin, Serum / Albumin, Serum
Protein, Total, Serum / Protein, Total, Serum
A/G Ratio / A/G Ratio
Globulin, Total / Globulin, Total
Alkaline Phosphatase, Serum / Alkaline Phosphatase, Serum
ALT (SGPT) / ALT (SGPT)
AST (SGOT) / AST (SGOT)
Bilirubin, Total / Bilirubin, Total
CBC with Differential / CBC with Differential
Hemoglobin / Hemoglobin
Hematocrit / Hematocrit
RBCs / RBCs
RDW (RBC distribution width) / RDW (RBC distribution width)
MCV / MCV
MCH / MCH
MCHC / MCHC
Platelet count / Platelet count
WBC / WBC
Segmented neutrophils / Segmented neutrophils
Band forms / Band forms
Basophils / Basophils
Eosinophils / Eosinophils
Lymphocytes / Lymphocytes
Monocytes / Monocytes
CMP (Comprehensive Metabolic Profile) / CMP (Comprehensive Metabolic Profile)
Albumin / Albumin
Alkaline phosphatase / Alkaline phosphatase
ALT (alanine aminotransferase) / ALT (alanine aminotransferase)
AST (aspartate aminotransferase) / AST (aspartate aminotransferase)
BUN (blood urea nitrogen) / BUN (blood urea nitrogen)
Calcium / Calcium
Chloride / Chloride
CO2 (carbon dioxide) / CO2 (carbon dioxide)
Creatinine / Creatinine
Glucose test / Glucose test
Potassium test / Potassium test
Sodium / Sodium
Total bilirubin / Total bilirubin
Total protein / Total protein
Creatine kinase (CK) isoenzymes / Creatine kinase (CK) isoenzymes
CK-BB / CK-BB
CK-MB (cardiac) / CK-MB (cardiac)
Troponin / CK-MM
Creatine phosphokinase (CPK) / Creatine phosphokinase (CPK)
Creatinine / Creatinine
Electrolytes / Electrolytes
Calcium / Calcium
Calcium, ionized / Calcium, ionized
Chloride / Chloride
Magnesium / Magnesium
Phosphate / Phosphate
Potassium / Potassium
Sodium / Sodium
Lipid Profile / Lipid Profile
Cholesterol, total / Cholesterol, total
HDL cholesterol / HDL cholesterol
LDL cholesterol / LDL cholesterol
Triglycerides / Triglycerides
Liver Panel (Liver function panel) / Liver Panel (Liver function panel)
ALT / ALT
AST / AST
ALP / ALP
Albumin / Albumin
Total protein / Total protein
Bilirubin / Bilirubin
GGT / GGT
LD / LD
PT / PT
Urinalysis / Urinalysis
Color / Color
Clarity/turbidity / Clarity/turbidity
pH / pH
Specific gravity / Specific gravity
Glucose / Glucose
Ketones / Ketones
Nitrates / Nitrates
Leukocyte esterase / Leukocyte esterase
Bilirubin / Bilirubin
Urobilirubin / Urobilirubin
Blood / Blood
Protein / Protein
WBCs / WBCs
Squamous epithelial cells / Squamous epithelial cells
Casts / Casts
Crystals / Crystals
Bacteria / Bacteria
Yeast / Yeast
Other Labs / Other Labs

Acknowledge for Submission:

ARCHETYPE INNOVATIONS’ NEEHR PERFECT ASSIGNMENT AGREEMENT

By submitting your content to Neehr Perfect via , you are acknowledging and accepting the following. Do not submit content that you do not have rights to assign to Neehr Perfect per this agreement.

THIS ASSIGNMENT AGREEMENT, is entered into by and between the author and copyright owner named below (“Assignor”) and Archetype Innovations, LLC ("Assignee").

FOR GOOD AND VALUABLE CONSIDERATION, the receipt and sufficiency of which are hereby acknowledged, Assignor and Archetype agree as follows:

1. Assignor does hereby assign, sell, transfer, set over and deliver unto Assignee all of its right, title and interest in and to the following copyrighted materials listed in Exhibit A attached hereto and incorporated by reference herein (hereinafter, the “Materials”), subject to Assignor’s reservation of rights in Section 4, below.

2. Assignor represents and warrants that Assignor is the creator of the Materials and is the sole the owner of all intellectual property rights in the Materials, including but not limited to all registered, unregistered, statutory and common law copyrights. Assignor further represents that Assignor is not prohibited, prevented, or otherwise restricted by law, contract, or any other means, from freely and voluntarily assigning to Assignee all of Assignor’s right, title and interest in and to the Materials.

3. Assignor agrees that Assignor will, any time and from time to time, upon receipt of written request, execute and deliver to Assignee, including its successors and assigns, any new or confirmatory instruments which may be necessary in order to protect or fully assign and transfer to and vest in Assignee, and/or its successors and assigns, its right, title, and interest in and to the Materials.

4. Assignee agrees that Assignor retains the right, as the author of the Materials, to continue to use, revise, and add to the Materials in connection with Assignor’s licensed use of Assignee’s copyrighted software products. In addition, Assignee agrees that it will give Assignor credit for being the original author of the Materials in any publication, licensing, display, distribution or other use of the Materials, including but not limited to use of the Materials in connection with any of Assignee’s copyrighted software products.

5. This Agreement sets forth the entire agreement of the parties with respect to the assignment of the Materials, superseding all prior agreements and understandings, and may be amended only in writing. All notices shall be in writing and given to a party at the address set forth in this Neehr Perfect Content Submission. This Agreement shall be governed by and construed in accordance with the laws of the state of Minnesota, without giving effect to the conflict of laws principles thereof. This Agreement shall be binding upon and inure to the benefit of the successors and assignees of Assignor and Assignee.

Thank you for your submission! We are always open to new educational content to benefit healthcare education and individual faculty and students. Your submission assists us in helping educators to teach and prepare the next generation of healthcare professionals.

It is our policy to review and consider all requests for a chart, or a request for edit in a current chart. You will receive an email from us advising you of the status of your submission on the next of the following dates: February 15th, June 15th, or October 15th. Best of luck!