Case Study 3: Jean Kasper

Transcription

1 1 Case Study 3: Jean Kasper Exercise 3.1: Registering the patient with full demographic and insurance information. 1. Open Medware by Sage. 2. Click the Insert Button. 3. On the General Tab, type in the following information in the appropriate fields: a. Last Name: <initials>kasper b. First Name: Jean c. Middle Initial: L. d. Generation: Leave this field blank. e. Do not check the box next to Is the guarantor the legal representative? (Note: this indicates who will be responsible for paying the bills.) f. Social Security number: g. Account number: <initials> 72 h. Address: 8900 Tower Avenue i. Zip Code: j. Home Phone Number: (651) k. Provider: Click on the arrow next to this field. Highlight Caryn <initials>johnson. Click Select. l. Assistant: Leave blank m. Default Referring Physician: Leave blank. n. Sex: Female o. Date of birth: 11/10/1970 p. Martial status: Married. q. Employment status: Employed. r. Fee schedule: Click on the arrow next to the field. Highlight Commercial Insurance. Click Select. s. Patient Comment: Leave blank t. Click OK.

2 2 4. Double click on your newly created patient and it will bring up the demographic screen that was just created. Click on the Insurance Tab. 5. Click on Insert to Add Patient Insurance. 6. Click Insert again to add a new patient insurance. 7. Code: click the arrow to the side of this field and then click on Insert. o Code: 55 o Company: Humana o Carrier Type: Other o Address: 1650 Tower Building o Zip: o Contact person: Leonard Mattle o Phone: (888) o Click OK.

3 3 8. Highlight the new entry: Humana and click Select. 9. Type in the information found in the box below: 10. Go to the Employer Info section found in the lower, left corner of the screen and fill in the information found in this box:

4 4 11. When finished, click OK. 12. Highlight Telltale Signs and click Select. 13. Go the Guarantor section found in the lower, right corner of the screen and fill in the information found in this box, and the click OK:

5 5 14. Your screen will now look like this:

6 6 15. Click on the Advanced Tab. Billing Cycle: Click on the arrow next to this field; highlight 1st of MO and click on Select. 16. Click on the Log Tab. Click Insert. Type in the information found in this box, and click OK: 17. Click on the Contacts Tab. Click Insert. Type in the information found in this box, and then click OK:

7 7 Exercise 3.2: Create a claim in MedWare by Sage 1. On the Patient Claims screen, highlight the desired patient (Jean Kasper). 2. Click Insert on the right hand side of the open box.

8 8 3. Claim date: Choose today s date as the default. 4. Provider = 90, Fee Schedule = BCBS, and Primary = 55 should all be filled in for you. 5. Dx 1 Type in Cellulites and abscess of the hand. Click OK.

9 9 Exercise 3.3: Set-up Instructions Creating a Picture for the Patient Note: Prior to starting Exercise 3.4, the following steps must be completed in order to create documents and images that will be attached to patient charts. 1. Open the Internet on your computer. 2. Type the web address: 3. From the left navigational bar, under Companion Disciplines, choose Allied Health. 4. Click on the title Using the Electronic Health Record in the Health Care Provider Practice. 5. On the left navigational menu, click on MedWare Chart Exercises. 6. Click on one of the thumbnail images (you are selecting the face of Jean <initials>kasper.) 7. Click Save at the first prompt. 8. Name the file as Jean <initials>kasper and save it to place of your choosing on your computer. Click Save. 9. Click Close. 10. Close the Internet. You are now ready to proceed to Exercise 3.4 Exercise 3.4: Adding/attaching an image to a patient s chart 1. Open Medware Chart (if not already open). 2. Click Charting and choose Patient Charts (if not already open). 3. Highlight Jean <initials> Kasper. 4. With Jean <initials> Kasper s name still selected, highlight the claim for Jean <initials> Kasper. 5. Click Edit Chart. 6. Click the icon for Attach Scanned Images. 7. A. If this is your first time attaching a document, a popup screen will ask if you would like to add an image to this patient s chart. Click Yes, and proceed to Step 8. B. If this is not the first time an image is attached to a patient s chart, click the New button, located at the top of the screen. 8. Browse to the file you created for Jean <initials> Kasper s and highlight the file name. 9. Click Open. The image is now attached to Jean <initials> Kasper s chart. 10. Close out of MedWare Chart when you are finished. Exercise 3.5: Adding an Allergy 1. Open MedWare Chart.

10 10 2. Click Charting, and then Patient Chart. 3. Select Jean <initials>kasper from the patient list and click Edit Chart. 4. Click on the Allergies tab. 5. Click New. 6. Type Latex in the Allergy field. 7. Type Hives in the Description field. (Note: Descriptions are a way to document and communicate what kind of reaction the patient is having in regards to their allergy.) 8. Click Save. Latex has been added to the allergy list. Exercise 3.6: Entering Chief Complaint or Vitals 1. Open Medware Chart. 2. Click Charting and choose Patient Charts. 3. Highlight Jean <initials>kasper. 4. Highlight the claim for Jean <initials>kasper and click Edit Chart. 5. Click on the Vital Hx tab. 6. Type in the Vitals Sign information as you see in the box below: 7. Click Save. 8. Click Close.

11 11 Exercise 3.7: Adding Content to a SOAP Note Template 1. Open Medware Chart. 2. Click Charting and choose Patient Charts. 3. Highlight Jean <initials> Kasper. 4. Click on the claim for Jean <initials> Kasper and click Edit Chart. 5. Click the Select Template icon. Recall that this icon is the yellow icon above the word Name. 6. Highlight <initials> SOAP Note and click OK. 7. A template appears on the screen. 8. Type the following text next to each heading. Important note: A physician would normally document the Assessment and Plan for the patient, but here you may enter them for educational purposes. SUBJECTIVE: The patient comes in today with a chief complaint of red, swollen, painful area on her right hand. States this started five days ago. She states that her fingers have swollen and her ring became stuck in her finger. Her husband cut her ring off, and noticed that there was a small cut to the under side of the fourth finger and since it has become red, swollen, and painful. The patient is afebrile and denies any other complaints at this time. OBJECTIVE: Blood pressure is 122/82, temperature is 97.3 tympanic, and weight is 195 pounds. Heart: regular rate and rhythm without murmur or rub. Lungs are clear to auscultation. The right hand shows there is edema and erythema noted to the MCP joints of the fourth finger with erythema around the MCP joint of the third and fourth finger extending approximately 2 cm on to the hand. There is full range of motion of the joints. There is good capillary refill. ASSESSMENT: CELLULITIS OF THE RIGHT HAND. PLAN: The patient was given an IM injection of Rocephin in the office as well as a prescription for Bactrim DS, one p.o. b.i.d x10 days. I advised the patient to perform warm soaks to the hand three to four times a day as well as informed to keep the extremity elevated, and Tylenol and Motrin as needed for pain, and follow up in the office next week for a recheck or sooner as needed. Advised her to watch for any spreading or redness, increased pain, or fever.

12 12 9. Click Save when you are finished documenting the chart note. Exercise 3.8: Create a Prescription/Adding a Medication 1. Open MedWare Chart. 2. Click Charting and choose Patient Charts. 3. Highlight Jean <initials> Kasper. 4. Highlight the claim for Jessica Hamel and click Edit Chart. 5. Click on the Rx tab. 6. Click on Patient Rx Worksheet. 7. Click Yes at the prompt No medications, do you wish to add some? Use today s date as the date prescribed.

13 13 The provider box may already have Jean <initials> Kasper s physician populated. If so, go to the next step. If not, click on the ellipse button, and highlight a provider that is listed. Click OK. Medication Type in Bactrim DS. Strength field 100 mg Take Take one Q12H Route - PO Dispense - 20 Units Tablets Duration - 10 days Refills - 0 Precautions - NA Click OK. Note: Leave blank. Dispense as written Prescribed as other practice 8. Click Save. 9. Click Close when you have finished.