1. Learning Medical Record Software
CHAPTER
THREE
TWO
Learning Medical Record Software

2. Adding Entry Details to Findings
Entry Details add further clarification to encounter note.
Entry Details are located at bottom of screen.

3. Two Rows of Entry Details Fields
First row of fields contains description of currently highlighted finding, note field for adding free-text about current finding, four buttons.
Second row contains following fields: prefix, modifier, result, status, episode, onset, duration, value, unit.

4. Two Rows of Entry Details Fields
All fields in Entry Details section apply to a single finding; one currently selected or highlighted.

5. Guided Exercise 18: Recording a Value
Value field can be used to enter a value about any type of finding.
Unit field is related to Value field; describes unit of measure for value.
Step 1
Make sure Daily Coffee consumption is current finding.

6. Guided Exercise 18: Recording a Value
Step 2
Locate Value and Unit fields in Entry Details section at bottom of screen; already contains words “cups per day.”
Click mouse in Value field; type “7–8”; press Enter key on keyboard.
Compare screen with Figure Text in encounter note should read: “Behavioral: Daily coffee consumption was 7-8 cups per day.”

7. Guided Exercise 18: Recording a Value
Figure 3-25: Recording the value 7-8 and unit cups per day.

8. Using Free Text
Free text: text is not codified and might contain anything.
Entry Details fields are stored as fielded data.
Less free text used in the EHR the better.

9. Guided Exercise 19: Adding Free Text
Patient reports she has recently stopped drinking coffee.
Step 1
Click on small plus sign next to Daily coffee consumption to expand list of findings.
Locate finding “recently decreased”; click mouse on red button.
Compare your screen to Figure 3-26.

10. Guided Exercise 18: Recording a Value
Figure 3-26: Patient reported decreased coffee consumption.

11. Guided Exercise 19: Adding Free Text
Step 2
Look at Entry Details section at bottom of screen.
Click mouse in free-text field. Type “because she stopped all coffee” in field; press Enter key on keyboard.
Compare your screen with Figure 3-27.

12. Guided Exercise 19: Adding Free Text
Free text added: because she stopped all coffee.

13. Guided Exercise 20: Recording Objective Findings
Px tab: used to record observations and results of physical examination and measurements and vital signs recorded during encounter.
Step 1
Position mouse pointer over Px tab; click mouse once.
Physical Examination list displayed. Notice that list is organized by body systems.

14. Guided Exercise 20: Recording Objective Findings
Step 2
Click small plus sign next to “Head” to expand list.
Locate finding “Exam for evidence of injury”; click mouse on blue button.
Compare your screen to Figure 3-28.
Blue button should be filled in and text “No evidence of a head injury” should be recorded in encounter note pane.

15. Guided Exercise 20: Recording Objective Findings
Figure 3-28: No evidence of head injury.

16. Guided Exercise 20: Recording Objective Findings
Step 3
Look at Entry Details field for Result.
It was previously blank but now contains word “normal.”
Example of how the EHR software can set field for you based on assumption that is normal not to have a head injury.

17. Guided Exercise 21: Setting the Result Field
Step 1
Using mouse, scroll list of physical examination findings until you see “Neurological System.”
Expand list by clicking on small plus sign next to Neurological System.

18. Guided Exercise 21: Setting the Result Field
Step 2
Locate finding “Cognitive Functions”; highlight finding by clicking mouse on description.
Compare your screen to Figure 3-29.

19. Guided Exercise 21: Setting the Result Field
Figure 3-29: Neurological/Cognitive Functioning finding.

20. Guided Exercise 21: Setting the Result Field
Step 3
Locate Result field in Entry Details section at bottom of screen.
Click mouse on button with down arrow in field.
Drop-down list of choices (Figure 3-30) will appear.

21. Guided Exercise 21: Setting the Result Field
Results are set through the Entry Details and signify what a particular finding revealed about the system it is associated with.
Figure 3-30: Drop-down list for Result field.

22. Guided Exercise 21: Setting the Result Field
Step 3 (cont.)
Position mouse pointer on result “normal;” click mouse button.
Field will display word “normal,” blue button will have automatically been selected, encounter note will read “Cognitive functioning was normal.”

23. Guided Exercise 22: Adding Detail to Recorded Findings
In this exercise, you will add status information to patient's reported symptom.
Step 1
Select finding for Edit by moving mouse pointer over underlined words “Chronic/recurring” headache in right pane.
When mouse pointer changes to a hand, click mouse button.

24. Guided Exercise 22: Adding Detail to Recorded Findings
Step 1 (cont.)
Px tab in left pane should be replaced by Edit tab.
Chronic/recurring headache is now current finding.

25. Guided Exercise 22: Adding Detail to Recorded Findings
Step 2
Locate Status field in Entry Details section at bottom of screen.
Click mouse on button with down arrow in status field.
Drop-down list of phrases (Figure 3-31) will appear.

26. Guided Exercise 22: Adding Detail to Recorded Findings
Step 3
Position mouse pointer on status “inadequately controlled”; click mouse button.

27. Guided Exercise 22: Adding Detail to Recorded Findings
Step 3
Field will display portion of phrase; text in encounter note will change to “Chronic/recurring headaches recently worse which is inadequately controlled.”

28. Guided Exercise 23: Adding Episode Detail to Findings
In this exercise, you will add information about frequency of patient's headaches.
Step 1
Finding “Chronic/recurring” headache should still be selected for edit. If not, repeat step 1 of previous exercise.

29. Guided Exercise 23: Adding Episode Detail to Findings
Step 2
Locate label “Episode” in Entry Details section at bottom of screen; click mouse on Episode button.
Episode window (Figure 3-32) will be invoked; used to record information about intervals and repetitions at which findings occur.

30. Guided Exercise 23: Adding Episode Detail to Findings
Figure 3-32: Episode window (numeric controls circled in red).

31. Guided Exercise 23: Adding Episode Detail to Findings
Step 2 (cont.)
Numeric value of a field in Episode window is increased or decreased by clicking on up or down arrow buttons next to numeric field (circled in Figure 3-32).
Units time measured are set by clicking on one of white circles next to Minutes, Hours, Days, Weeks, Months, or Years.

32. Guided Exercise 23: Adding Episode Detail to Findings
Step 3
Locate “Occurring from.”
Set it to 1 day by clicking on up arrow button once; then clicking on circle next to Days.
Step 4
Locate “Lasting from.”
Set it to 2 hours by clicking on up arrow button twice; then clicking on circle next to Hours.

33. Guided Exercise 23: Adding Episode Detail to Findings
Step 5
Locate “Lasting to.”
Set it to 4 hours by clicking on up arrow button four times; then clicking on circle next to Hours.

34. Guided Exercise 23: Adding Episode Detail to Findings
Step 6
Compare your screen to Episode window in Figure 3-32; click on OK button.
Look at encounter note in right pane. Does text read “Chronic/recurring headaches recently worse occurring 1/day lasting 2–4 hours which is inadequately controlled”?

35. Guided Exercise 24: Recording the Assessment
This exercise will give experience in navigating and expanding tree of findings.
Step 1
Position mouse pointer on tab “Dx”; click mouse.
Diagnosis, Syndromes, and Conditions list should be displayed in left pane of window.

36. Guided Exercise 24: Recording the Assessment
Step 2
Scroll list downward until you see “Neurologic Disorders”(highlighted in Figure 3-33.)
Click on small plus sign to expand list.
Locate “Headache Syndromes” in list and click on small plus sign.

37. Guided Exercise 24: Recording the Assessment
Figure 3-33: Dx tab with Neurologic Disorders highlighted.

38. Guided Exercise 24: Recording the Assessment
Step 3
Scroll list further downward until you see “Benign syndromes” (highlighted in Figure 3-34); click on small plus sign.
Step 4
Scroll list further downward until you see “Drug-induced headache”; click on small plus sign.

39. Guided Exercise 24: Recording the Assessment
Figure 3-34: Dx tab scrolled to Benign syndromes.

40. Guided Exercise 24: Recording the Assessment
Step 5
Scroll list further downward until you see “Vasoconstrictor withdrawal headache”; click on small plus sign.
See fully expanded list of findings in Figure 3-35.

41. Guided Exercise 24: Recording the Assessment
Figure 3-35: Dx tab—assessment: withdrawal headache from caffeine.

42. Guided Exercise 24: Recording the Assessment
Step 6
Position mouse pointer on red button next to “From caffeine”; click mouse.
Compare your screen to Figure 3-35.
Finding “Vasoconstrictor withdrawal headache from caffeine” should be recorded in encounter note under new heading: “Assessment.”

43. Guided Exercise 25: Recording Treatment Plan and Physician Orders
In this exercise, you will add a free-text finding and enter information through a special free-text window.
Step 1
Position mouse pointer on Rx tab and click mouse button.
Medcin Therapy list will be displayed.

44. Guided Exercise 25: Recording Treatment Plan and Physician Orders
Step 2
Scroll to bottom of list, locate and highlight finding labeled “Free Text” (Figure 3-36; do not click a red or blue button).

45. Guided Exercise 25: Recording Treatment Plan and Physician Orders
Figure 3-36: Free-text finding (highlighted) on Rx tab.

46. Guided Exercise 25: Recording Treatment Plan and Physician Orders
Step 3
In lower right corner of screen are four buttons. Finding Note button (circled in red in Figure 3-37).
Position mouse pointer on Finding Note button; click mouse; Finding Note window will be invoked (Figure 3-37).

47. Guided Exercise 25: Recording Treatment Plan and Physician Orders
Figure 3-37: Finding note window used for free text (button circled in red).

48. Guided Exercise 25: Recording Treatment Plan and Physician Orders
Step 4
Area in window is larger than free-text field.
Window includes spell checker.
Insert text feature allows frequently used text to be stored inserted as free text.
Type following text into Finding Note window:
“Eat regular meals, get plenty of exercise, and limit intake of caffeine, and alcohol.”

49. Guided Exercise 25: Recording Treatment Plan and Physician Orders
Step 4 (cont.)
When finished, click mouse on button labeled “Close the note form.”
This will add text to encounter note under a new section title “Therapy.”

50. Introduction to Using Forms
Forms make it convenient to enter findings or free text without locating and selecting finding from nomenclature.
In following two exercises, you will use forms to add information to encounter note.

51. Guided Exercise 26: Recording the Chief Complaint
Step 1
Locate button in Toolbar labeled “Chief” (circled in Figure 3-38).
Position mouse pointer over it; click mouse.
Step 2
Chief complaint window will be invoked.
Instead of just recording free text, it will automatically associate text with finding “Chief complaint.”

52. Guided Exercise 26: Recording the Chief Complaint
Figure 3-38: Chief complaint note form invoked from toolbar.

53. Guided Exercise 26: Recording the Chief Complaint
Step 3
Type following text into finding note window:
“Headaches for more than 5 days.”
When finished, compare screen to Figure 3-38.
Position mouse on button labeled “Close the note form”; click mouse.
This will add new section to encounter note titled “Chief complaint” followed by text you typed.

54. Guided Exercise 27: Recording Vital Signs
Step 1
At bottom of screen are five tabs labeled “ADT,” “Encounter,” “Forms,” “Manage,” “Nursing.”
Position mouse pointer over tab labeled “Forms” (circled in red at bottom of Figure 3-39); click mouse.

55. Guided Exercise 27: Recording Vital Signs
Figure 3-39: Forms tab and forms button (both circled in red).

56. Guided Exercise 27: Recording Vital Signs
Step 2
Locate and click on button labeled “Forms” in top row of Toolbar at top of screen (circled in red in Figure 3-39).
This will invoke Forms Manager window (Figure 3-40); lists forms used in Student Edition.

57. Guided Exercise 27: Recording Vital Signs
Figure 3-40: Select Vitals from list in Forms Manager window.

58. Guided Exercise 27: Recording Vital Signs
Step 2 (cont.)
Locate and click on form labeled “Vitals” in Form Manager window (Figure 3-40).
This opens form shown in Figure 3-41.

59. Guided Exercise 27: Recording Vital Signs
Figure 3-41: Vital Signs Form for Rosa Garcia.

60. Guided Exercise 27: Recording Vital Signs
Step 2 (cont.)
Enter Ms. Garcia's vital signs into corresponding fields:
Temperature: 98.6
Respiration: 24
Pulse: 78
BP 120/78
Height: 64
Weight: 140

61. Guided Exercise 27: Recording Vital Signs
Step 2 (cont.)
When all vital signs entered, compare screen to Figure 3-41; click mouse on Encounter tab (circled in red) at bottom of screen.
Vital signs information will be recorded in encounter note on right pane under Physical Findings section.

62. Guided Exercise 27: Recording Vital Signs
Step 3
Look at results of Vital Signs entry as they appear in encounter note.
There is a tab on top of right pane labeled “Outline View.”
This tab will display same outline in right pane, as was displayed on Forms tab.
When you have finished looking at note, exit Student Edition software.

63. Visually Different Button Styles
Many EHR software packages are based on Medcin Nomenclature.
Each vendor has created unique visual style.
Although they share common nomenclature, the EHR may look quite different.
One difference is the look of buttons.

64. Chapter Summary In this chapter you have learned about:
Student Edition software
Menus and Toolbar
Nomenclature Pane; Note View Pane
Entry Detail fields
Chief complaint
Free-text Note
Outline View
Vital Signs forms

65. Chapter Summary
EHR software allows clinicians to document patient exam by selecting findings for:
Symptoms
History
Physical examination
Tests
Diagnoses
Therapy

66. Chapter Summary Menu bar and Toolbar: located at top of window.
Menus are Select, Enter, Options, Forms, Summary, Graph, Help.
Within these are lists of functions in Student Edition software.

67. Chapter Summary Toolbar is located at top of screen.
Consists of two rows of buttons, each containing small picture (icon); brief label.
Purpose is to allow quick access to commonly used functions.

68. Chapter Summary
Medcin Nomenclature Pane is located in left pane of window.
Displays lists of Medcin findings from which you choose when documenting patient exam.
Eight tabs: Sx (symptoms), Hx (history), Px (physical examination), Tx (tests), Dx (diagnosis, syndromes, conditions), Rx (therapy or plan), Edit, Browse.

69. Chapter Summary
Encounter View Pane is located in right pane of window.
Two tabs: Note View and Outline View.
Note View: displays findings accompanied by narrative text.
Outline View: displays findings selected and appropriate ICD-9-CM or CPT-4 codes.

70. Chapter Summary
Entry Details fields are located at bottom portion of screen.
Consists of two rows of fields and four buttons that affect only currently selected finding.
User can add detail or free text to finding, or remove finding from encounter note.

71. Documenting the Encounter
First step in every encounter is to select patient, then open an existing encounter or create a new encounter.
Important to use exact date, time, reason.
Selecting patients, encounters, adding chief complaint, notes, selecting forms open small windows that close when user is finished.

72. Documenting the Encounter
Left pane displays lists of Medcin findings in a tree structure where small plus signs indicate more detailed findings are available.
Findings are selected by clicking on buttons with red or blue circles in them located next to each finding.