EHR: Scavenger Hunt II

Metadata Author: Date Submitted: Editor: Competency Domain(s) Competency Subdomain(s) Competency Task/Skill(s)

Dawn Sella Graney, RHIA, CPC 10/07/2008 Barbara Glondys Health record data collection tools IA. Health Data Structure, Content and Standards AS IA1. Collect and maintain health data (such as data elements, data sets and databases).

Knowledge Cluster Content(s) Competency Level Associate, Baccalaureate, or Both? Suggested Course Usage V-Lab Technology(ies) Used Estimated Completion Time (in 15-minute intervals) Necessary Prerequisite Knowledge

Data Requirements

IA2. Conduct analysis to ensure that documentation in the health record supports the diagnosis and reflects the patient’s progress, clinical findings and discharge status. N/A Both Fundamentals of HIM EHR Application 60 Minutes Basic understanding of EHR Loading Citrix. Basic understanding of searching for patients in the EHR. Basic Understanding of the format of, and navigation through, the Academic EHR. Records in EHR

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Objectives: After completing this activity, you will be able to... Conduct numerous patient MRN lookups in the Cerner Powerchart EHR Navigate the various screens in Powerchart Change data views in Powerchart Find and review patients’ demographics Find and review patients’ clinical data

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Introduction As you embark on a career as an HIM professional, it is imperative that you understand how information is stored in EHR applications. This exercise will introduce you to searching for data in the ATHENS/Cerner EHR. Warning: Before starting this activity you must download Citrix. Refer to the EHR Student Guide provided to you by your instructor for additional instructions. You must also have your Virtual Lab student registration confirmed in the Web Registration System. If you have not done that, please see your instructor for additional assistance.

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Lab Activity Task # 1

Task Logging into the EHR

Detailed Steps If you have downloaded Citrix to your computer, log into the Cerner EHR to get started: 1. Go to your pc internet browser and type the URL: https://schlmn.cernerworks.com/AHIMA 2. Type the username: SCHLMN 3. Type the password: ATHENS*5 At the next screen:

4. Double-click on Power Chart 5. Type your 7-digit AHIMA member ID 6. Type your password

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Getting Started in the EHR

Note: If you’ve logged into the EHR before, your password is one that you’ve created for yourself the first time you logged in. If you’re logging in for the first time, your password is the same as your 7-digit ID. You’ll need to create your own password when you get a successful login. In this exercise you will identify patients in the EHR by using the Patient Search. Although you will be searching by medical record number (MRN), you will be using the shared “VLab” cases built in the system. Note: all patients with last names beginning with “Vlabxx” (e.g., Vlabfemale,Ortho; Vlabmale,Vasc) are shared patients. These records are based on actual hospital cases, and intended for use by all schools. Never enter any data on these patients, or the program will risk losing Vlab privileges. To conduct a Patient Search:

Click the “Patient” at the top of the toolbar. Then click on Search, OR Click on the binoculars icon on the top right side of the menu bar

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Either of these steps will open the search screen.

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Patient Search Exercises and Questions:

1. Search for patient MRN 000004036. Record the patient name. a. What is this patient’s date of birth? b. What was this patient’s HCT on 6/24/2004 at 7:58? c. What surgery did this patient have on 6/24/2004? d. What is this patient’s religion? 2. Search for patient MRN 000004032. Record the patient name. a. How old is this patient? b. Review the anesthesia record. For what procedure did he receive anesthesia on 1/12/2004? (Abbreviation is OK) c. What is this patient allergic to? 3. Search for patient MRN 000002842. Record the patient name. Select the Inpatient encounter. a. Does this patient have an advance directive? b. If yes, who has medical power of attorney? c. What is the patient’s Glasgow coma score on 7/31/2006 at 8 PM? d. Review this patient’s 7/31/2006 ER report. What is listed as his chief complaint? e. Review problems and diagnoses for this patient. What year did he have a myocardial infarction? 4. Search for patient MRN 000002796. Record the patient name. a. Review the 11/1/2006 History and Physical. Read the chief complaint. At what restaurant was the patient when he was “acting plastered”? b. What medication was added to the patient’s IV on 11/1/2006?

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5. Search for patient MRN 000004015. Record the patient name. a. What is this patient’s marital status? b. What was this patient’s BP, P & R according to the ER Triage Report? c. On 2/14/2005, the CT scan was of what area? What were the physicians looking for? 6. Search for patient MRN 000004035. Record the patient name. a. Which extremities were examined through the ultrasound on 3/5/2005? b. Review the discharge summary. What was the patient’s discharge date? c. What was the principal diagnosis? d. Who was the patient’s physician according to the discharge summary? e. How many units of IV heparin were ordered for this patient on 3/1/2005? f. Review the history and physical. Name the city and state from where the patient was flying home? g. The patient is allergic to tetracycline and what else? 7. Search for patient MRN 000004016. Record the patient name. a. Review the lipid results for 7/19/2004. What are her chol, trig, HDL, and LDL results? b. Review the neurological information. Will she allow clergy to visit? c. What home equipment does she use? d. Review the anesthesia report for 7/20/2004. Two medications were administered, fentenyl and which other drug? e. Review the discharge instruction sheet. How many times a day is she taking fish oil? 8. Search for patient MRN 000002843. Record patient name. a. What was the visit type for the 5/31/2006 encounter? b. On 1/5/2006 at 3:45 PM, what were the patient’s WBC and RBC results? c. On the patient’s Braden assessment, what activities does she do and how often? d. Review the patient’s problems and diagnoses. What year did she have a tonsillectomy and adenoidectomy? 9. Search for patient MRN 000002801. Record the patient’s name. a. Review the patient’s nuclear medicine report for 11/9/2006. What type of study did she have? b. Review the patient’s ED report for 11/7/2006 at 12:05 PM. What was her chief complaint? c. Review the consultation report for 111/7/2006. What was the name of the consulting physician? 10. Search for patient MRN 000002817. Record the patient name. a. What is this patient’s blood type? b. What surgery did the patient have on 2/10/2006? c. Review the pain assessment grid. On 2/10/2006 at 4:40 PM, where was her pain and what was the intensity?

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11. Search for patient MRN 000004018. Record the patient name. a. Review the Pre Op H&P for 1/10/2005. Under history of present illness, how large is the left frontal tumor? b. Review the 1/11/2005 pathology report. Were both macroscopic and microscopic views of the tumor documented? c. What were the routine chemistry results for sodium, potassium and chloride on 1/10/2005 at 7 AM? 12. Search for patient MRN 000002778. Record the patient name. a. What surgery did the patient have on 5/6/2006? b. Review the 5/6/2006 progress note-nurse. Where did she apply topical cream? c. What type of dressing was put on the area? 13. Search for patient MRN 000002818. Record the patient name. a. Review the 11/23/2006 1:45 PM progress note – labor and delivery summary. What were the baby’s Total APGAR scores? b. How much did the baby weigh? c. Review the problems and diagnoses. What year did she have a miscarriage?

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Exiting Cerner EHR

Great job! Now it’s time to close the charts and do a clean exit of the system. 1. Close the chart – go to “Chart”, top, at the left option of the screen click, scroll down to “close charts” and click. Note: this closes the charts you’ve been working on but not the EHR application. 2. Close EHR – the colored icon at the top of the Organizer screen is a teal door with a teal arrow. When you hover your mouse over it, the tool tip says “exit”. Click on this icon to close the EHR application.

3. Exit Citrix – the Cerner Citrix portal is still running. It may come to the screen automatically, if not, then select “welcome to CernerWorks” from the applications status bar at the bottom of your screen. 4. At the top of the CernerWorks panel you’ll see a small “logout” button --> click this button to close the Citrix session. A new CernerWorks login screen will appear. 5. At this point it is safe to X-out of (close) the screen Thank You!

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