7.Search for the record by MR# or patient name. (make sure that All statuses is selected from the dropdown menu of the Search box.) 8.Locate the correct encounter as indicated in the list of patients assigned for analysis. 9.Click on the MRN (medical record number). You will be prompted with the following screen:
¢If you have clicked on the wrong patient or encounter, click Cancel on the lower left of the screen. This action will take you back to the search screen. 10. Click on Document Imaging link underlined in blue locate in the top right portion of the screen. Patient documents will open. You may need to enlarge the new pop up screen for better view. (Make sure that Active X controls are enabled for proper functioning of this application.)
¢Scroll up and down as needed in the left section of this screen and locate patient documents loaded in the system. This is indicated by the blue link and the document type as shown in the figure above. 10.Locate necessary documents for record completion (such as History & Physical, Operative Report, Discharge summary, etc.) 11.Identify missing documents. Indicate what you feel should be in the medical record based on your readings in chapter 3 of the Johns Text book.
¢The standard statuses are dictate, transcribe, write, sign, and complete. oFor example indicate Operative Report dictate and sign Dont worry about the semantics of dictate, transcribe, write or complete. Identifying there is a deficiency is the main point here. 12. Record the deficiencies and take a screen shot and put in a MS word document. Below is a screen shot of a live system if you were to add the deficiency into the system. (You will not see this information)
Note the various deficiency types and statuses.
Completing the Lab Assignment
1.Go through the other 4 records and note the deficiencies on a MS Word document and take a screen shot of the Record Management System. You should have 5 records with deficiencies noted as well as the screen shot from the help menu. 2.Save the word document as HIT141Lab_Lastname_FirstInitial 3.Submit in week 7 iLab dropbox by the end of week 7.