Learning Medical Record Software CHAPTER THREE ONE Learning Medical Record Software

Overview The student software for this course is based on the MEDCIN nomenclature. Teaches EHR concepts by providing hands-on experience. Provides practical experience using an EHR. Each set of exercises designed to illustrate an EHR concept; will result in documented encounter note.

EHR Login Learn to log in to Student Edition software. Student login is your name or student ID. In healthcare facility your login will be unique; provides permanent record of your use of the system. If using school computer, you may be required to log in to school network first.

Guided Exercise 8: Starting Up the Software Locate and click on the icon. Type your student ID in the login screen and click the OK button.

Navigating the Software The window is divided into four interactive sections The Menu Bar and Toolbar: Allow you to select functions quickly and easily. The MEDCIN Nomenclature Pane: Displays findings in the nomenclature. The Encounter View Pane: Dynamically displays encounter notes as they are created. Entry Details: Allows entry of additional information to the findings.

Four Sections of the Window Menu bar Toolbar Note View Pane Nomenclature pane Entry Details Fields

Guided Exercise 9: Exiting and Restarting the Software Software can be exited in three different ways Through the exit button on the Toolbar. Through the red X button in the upper right. Through “Select” on the Menu bar. Functionally, all three methods do the same thing

Guided Exercise 9: Exiting and Restarting the Software Step 1 First word in Menu bar is “Select.” Position mouse pointer over word “Select” and click mouse button once. List of functions on Select menu will drop down. Menu items in gray text indicate a particular function is not applicable.

Guided Exercise 9: Exiting and Restarting the Software Step 2 Move mouse pointer vertically down list until Exit function is highlighted. Click mouse on word “Exit” to end program. Step 3 Start Student Edition software again by repeating Exercise 8, and logging in.

Guided Exercise 10: Using the Menu to Select a Patient The first step in all encounters is selecting the patient through “Select” on the Menu. Patient names can be navigated by scrolling through the list or searching by specific name. Step 1 Position mouse pointer over word “Select” in Menu bar at top of screen; click mouse button once.

Guided Exercise 10: Using the Menu to Select a Patient Figure 3-4: Functions on the Select menu.

Guided Exercise 10: Using the Menu to Select a Patient Step 2 Move mouse pointer vertically down list until Patient is highlighted. Click mouse on word “Patient” to invoke Patient Selection window (Figure 3-5).

Guided Exercise 10: Using the Menu to Select a Patient Figure 3-5: Selecting Rosa Garcia from Patient Selection window.

Guided Exercise 10: Using the Menu to Select a Patient Step 3 Student Edition Patient Selection window displays a list of all patients in system, last name, first name, patient ID number, date of birth. Field at top of window allows you to type patient's last name to find someone in a large list.

Guided Exercise 10: Using the Menu to Select a Patient Step 3 (cont.) Find patient named Rosa Garcia in Patient Selection window by typing “Garcia, R” in field. When “Rosa Garcia” is highlighted, click OK button. Clicking Cancel button will close window. Alternate method of selecting patient: visually locate patient's name, position mouse pointer over it, double-click mouse.

Guided Exercise 10: Using the Menu to Select a Patient Step 4 Once patient is selected, patient's name is displayed in title at top of window (Figure 3-6). Medcin Nomenclature (left pane) becomes active and first group of findings (symptoms) is displayed. Right pane containing encounter note is populated with student's name or ID and patient's name, sex, date of birth.

Guided Exercise 10: Using the Menu to Select a Patient Figure 3-6: Left pane displays Medcin nomenclature.

Guided Exercise 11: Navigating the Medcin Findings Look at the list of findings in the left pane. This is the nomenclature pane. Many are preceded by a small plus sign that allows you to expand the information. This is referred to as the tree structure of the software. Buttons used in the Nomenclature pane.

Guided Exercise 11: Navigating the Medcin Findings Tabs across the top of the left pane organize the nomenclature. Align with SOAP Sx and Hx: subjective Px and Tx: objective Dx: assessment Rx: plan Figure 3-9: Expanded list of findings for head-related symptoms

Guided Exercise 11: Navigating the Medcin Findings Step 2 Locate finding “head-related symptoms” in nomenclature symptoms list. Position mouse pointer over small plus symbol and click mouse button once. Compare left pane of screen with Figure 3-9 in your book.

Guided Exercise 11: Navigating the Medcin Findings Step 2 (cont.) List should have expanded to reveal additional head-related findings. Findings under “head-related symptoms” are indented.

Guided Exercise 11: Navigating the Medcin Findings Step 3 Position mouse pointer over small plus symbol for finding “headache” in indented list; click mouse. List expands further. Position mouse pointer over small plus symbol for finding “timing” indented under headache; click mouse. The list expands further.

Guided Exercise 11: Navigating the Medcin Findings Step 4 Position mouse pointer over small plus symbol for finding “chronic/recurring”; click mouse. Compare your list to Figure 3-10. This type of list is a tree. Small minus sign replaced small plus sign in button next to finding that has been expanded (“the tree has expanded”).

Guided Exercise 11: Navigating the Medcin Findings Figure 3-10: Fully expanded list of findings for headache.

Guided Exercise 11: Navigating the Medcin Findings Step 5 Position mouse pointer over small minus symbol next to finding “head-related symptoms”; click mouse button again. Expanded list of various types of head-related symptom findings will again be hidden from view (“view of tree has been collapsed)”. Your screen should look like Figure 3-8.

Guided Exercise 11: Navigating the Medcin Findings Figure 3-8: Locate the finding “head-related symptoms.”

Guided Exercise 12: Tabs on the Medcin Nomenclature Pane Step 1 Position mouse pointer over Hx Tab and click mouse once. List will change from Symptoms to History. Selected tab has appearance of being slightly raised from others.

Guided Exercise 12: Tabs on the Medcin Nomenclature Pane Step 2 Position mouse pointer over small plus next to “past medical history”; click mouse button to expand list. Step 3 Position mouse pointer over small plus next to “reported medications”; click mouse button to expand list.

Guided Exercise 12: Tabs on the Medcin Nomenclature Pane Position mouse pointer on light blue scroll bar; hold mouse button down while you drag mouse in downward motion. Continue scrolling list until you see all findings under “recently stopped medication.” Click on small plus sign next to finding “recently stopped medication.” Figure 3-12: Expanded past history (scroll bar is circled in red).

Guided Exercise 12: Tabs on the Medcin Nomenclature Pane Step 4 Position mouse pointer over Sx tab and click mouse once. Display will return to previous list (Figure 3-8).

Guided Exercise 11: Navigating the Medcin Findings Figure 3-8: Locate the finding “head-related symptoms.”

Guided Exercise 12: Tabs on the Medcin Nomenclature Pane Step 5 Position mouse pointer again over Hx tab; click mouse once. Notice list is expanded as when you left it.

Guided Exercise 12: Tabs on the Medcin Nomenclature Pane Step 6 Explore each remaining section of Medcin Nomenclature Pane by clicking on each of the remaining tabs. Look at type of findings in each tab. Expand or collapse list in any of the tabs.

Guided Exercise 13: Creating an Encounter Encounter: when doctor, nurse, or healthcare provider examines patient in facility, at home, or as an outpatient. Clinical notes documenting encounter are exam notes, provider notes, encounter notes. Record of findings of examination that occurred on specific date and time.

Guided Exercise 13: Creating an Encounter Case Study Exercises in this chapter concern a 27-year-old female patient who complains of headaches lasting for more than five days. She was previously consuming 7–8 cups of coffee a day and has recently stopped drinking all coffee.

Guided Exercise 13: Creating an Encounter Step 1 Name of patient Rosa Garcia should be displayed at top of Medcin window. If not, repeat Guided Exercise 10. Select menu has functions to select existing encounter or create new encounter. In this exercise, you will create new encounter.

Guided Exercise 13: Creating an Encounter Step 1 (cont.) Position mouse pointer over word “Select” in Menu bar; click mouse button. Move mouse pointer vertically down list until item “New Encounter” is highlighted; click mouse button.

Guided Exercise 13: Creating an Encounter Step 2 When you create new encounter, a window is invoked allowing you to set date, time, reason for encounter. Manually set date and time to May 1, 2012. Small gray buttons with left and right arrows are located at top of calendar window.

Guided Exercise 13: Creating an Encounter Step 2 (cont.) Clicking button with right arrow advances calendar one month for each click; left arrow takes calendar backward one month for each click.

Guided Exercise 13: Creating an Encounter Figure 3-13: Select New Encounter, set date/time May 1, 2012, 11:00 AM.

Guided Exercise 13: Creating an Encounter Step 2 (cont.) Click buttons on top of calendar until May is displayed. Click on year to modify to 2012. Position mouse pointer over day 1; click mouse button. First day will be highlighted with blue rectangle.

Guided Exercise 13: Creating an Encounter Step 2 (cont.) Time indicated on right side of window by white circles filled in center. Select time by clicking mouse in circles next to 11:00 and :00 and :AM. Each of the circles should become filled in.

Guided Exercise 13: Creating an Encounter Step 3 Reason for encounter is set in this window. Encounter Reason field is located just below calendar. To view list of reasons, position mouse pointer over button with down arrow in right side of field; click mouse. Drop-down list of reasons will appear (Figure 3-14).

Guided Exercise 13: Creating an Encounter Figure 3-14: Select 10 minute visit from list of reasons for encounter.

Guided Exercise 13: Creating an Encounter Step 3 (cont.) Scroll list of reasons. Highlight reason “10 minute visit” by moving mouse pointer over it. When reason is highlighted, click mouse button to select reason.

Guided Exercise 13: Creating an Encounter Step 4 Compare your screen to Figure 3-15. Set date, time, reason correctly. If date, time, or reason needs to be corrected, repeat previous steps. Locate button labeled OK in bottom of New Encounter window; position mouse pointer over OK button; click mouse. “Date and Reason for Encounter” window will close.

Guided Exercise 13: Creating an Encounter Figure 3-15: New encounter for a 10 minute visit, May 1, 2012, 11:00 AM.

Guided Exercise 13: Creating an Encounter Step 5 Encounter date, time, and reason “10 minute visit” should be displayed in title of window. Encounter date and time should be recorded in encounter note in right pane of window. Compare your screen with Figure 3-16; if it matches, proceed. If it does not, repeat steps 1–4.

Guided Exercise 13: Creating an Encounter Figure 3-16: New encounter for Rosa Garcia.

Data Entry of Clinical Notes Information is entered by clicking a button next to a finding in the nomenclature pane Finding and accompanying text are automatically recorded in encounter note displayed in right pane of window. Additional information about the finding may be added by using the Entry Details fields at the bottom of the Window

Data Entry: Click button next to a finding Buttons fill in with color when selected. Red button usually means observed or abnormal. Blue button generally means normal or not present.

Guided Exercise 14: Recording Subjective Findings When finding is recorded in encounter note on right pane, description of finding in left pane also changes to match selected state. Step 1 Make sure Sx tab in left pane is selected. Expand tree of “head-related symptoms” so list resembles expanded tree in left pane of Figure 3-18.

Guided Exercise 14: Recording Subjective Findings Figure 3-18: Expanded tree for head-related symptoms— Headache finding selected.

Guided Exercise 14: Recording Subjective Findings Step 2 Position mouse over red button for finding “Headache;” click mouse button. Compare your screen to Figure 3-18. Center of button should turn red indicating finding has been selected. Word “Headache” should have appeared on right pane in encounter note.

Guided Exercise 14: Recording Subjective Findings Step 2 (cont.) When you record first subjective finding, section title “History of Present Illness” is added to encounter note. Section titles are dynamically added or removed by the software based on findings selected.

Guided Exercise 14: Recording Subjective Findings Step 3 To further explore operation of red and blue buttons, position mouse over and click on blue button for headache instead. Center of blue button should fill in; red button should return to previous (cleared) state. Text in encounter note and finding description will both change to “No Headache.”

Guided Exercise 14: Recording Subjective Findings Step 3 (cont.) Click on red button to restore finding back to “Headache.” Make sure button is red and text in encounter note again reads “Headache” before proceeding to step 4.

Guided Exercise 14: Recording Subjective Findings Step 4 EHR information specific as possible. Click on small plus next to Headaches to expand tree. Locate finding Chronic/Recurring; click on red button. Did red button fill in? Did text change in encounter note?

Guided Exercise 14: Recording Subjective Findings Step 5 Patient reports headaches are getting worse. Notice small plus sign next to chronic/recurring; indicates there are more detailed findings available. Click on plus sign to expand tree. Compare your screen to Figure 3-19.

Guided Exercise 14: Recording Subjective Findings Figure 3-19: Selected findings: Headache chronic/recurring and worsening.

Guided Exercise 14: Recording Subjective Findings Step 6 In expanded list for chronic/recurring, click mouse on red button for “episodes recently worse.” Notice that software changes description of findings when you click red or blue button.

Guided Exercise 15: Removing Findings Step 1 Move mouse pointer over underlined finding “with episodes” in encounter note. Mouse pointer changes into shape of hand. While the hand is over finding, click mouse once. This will Edit the finding.

Guided Exercise 15: Removing Findings Step 2 Locate button with an X in lower right corner of the screen (circled in red in Figure 3-20). This is Delete button; position mouse pointer over Delete button; click once. Small window “dialogue” will appear (Figure 3-21). Dialogue asking you to confirm your intention to remove finding from encounter note. Click on OK button.

Guided Exercise 15: Removing Findings Select finding in note. Click the X button in the Entry Details section. Click OK.

Guided Exercise 15: Removing Findings Step 2 (cont.) Finding “with episodes” and text “recently worse” will be removed from encounter note. Left pane will remain on Edit tab; this is normal.

Guided Exercise 15: Removing Findings Step 3 Practice removing findings by repeating steps 1 and 2. When you remove last finding in a section, the section title will be removed automatically. Step 4 Restore Medcin Nomenclature list to left pane by positioning mouse over Sx tab and clicking once.

Guided Exercise 16: Recording More Specific Findings If you have all information before selecting finding, you can select most specific finding; Medcin will add surrounding text.

Guided Exercise 16: Recording More Specific Findings Step 1 If your screen does not resemble Figure 3-16, repeat necessary steps to select patient, select new encounter, and select Sx tab. Expand tree view of “head-related symptoms,” “headache,” chronic/recurring until you see full list (Figure 3-22).

Guided Exercise 16: Recording More Specific Findings Figure 3-22: Chronic/recurring headaches recently worse.

Guided Exercise 16: Recording More Specific Findings Step 2 Position mouse pointer over red button for finding “episodes recently worse”; click mouse. Compare your screen with Figure 3-22. Did red button fill in? Compare text of encounter note in Figure 3-22 with text in Figure 3-20. The two notes are different but medically equivalent.

Guided Exercise 17: Recording History Findings History tab is used to record patient's past medical, surgical, family, and social history. Step 1 Position mouse pointer over Hx tab and click mouse once.

Guided Exercise 17: Recording History Findings Step 2 Expand tree by clicking small plus signs next to “social history,” “behavioral history,” “caffeine use.” Left pane of window should resemble Figure 3-23.

Guided Exercise 17: Recording History Findings Figure 3-23: Hx list—coffee consumption.

Guided Exercise 17: Recording History Findings Step 3 Position mouse over red button next to finding “coffee consumption (—cups/day).” Click mouse button. Center of button should turn red and “Behavioral: Daily coffee consumption” should appear in encounter note pane on right pane.

Guided Exercise 17: Recording History Findings Step 3 (cont.) Compare your screen to Figure 3-24. Note that two new titles were added as well: Personal history and Behavioral.

Guided Exercise 17: Recording History Findings Figure 3-24: Daily coffee consumption.