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EHR Demo Scenarios – Family Practice

#1
Walk-in Acute Patient
30 year old male, married patient, works in the maintenance department for Sugarbush Resort. Patients presents, bent over , complaining of acute back pain from shovel ing snow on the job. Brings workman’s comp papers with him. PMH: back problems Medications: HPI: lower back pain, more severe on right side EHR should demonstrate: Documentation of vital signs, height, weight Documentation of head-to-toe physical assessment Copyright 2009 Vermont Information Technology Leaders, Inc Complex Patient
45 year old female, smoker, in the middle of a divorce, has two twenty-something unemployed children living with her. They are al on Mediciad. PMI: HTN, DM, Depression Medications: HPI: Two-day history of chest pain, non-radiating EHR must demonstrate: Documentation of vital signs, height, weight Documentation of head-to-toe physical assessment Copyright 2009 Vermont Information Technology Leaders, Inc Non-conventional Patient Taking Herbal Remedies
35 year old male, single, works for Forest Service; new patient who thinks he may have Lyme disease. HPI: chronic fatigue, rash, headache, swol en stiff left hand Medications: Review of medications, al ergies, drug interactions, amount of herbs consumed in one day Documentation of vital signs, height, weight Documentation of head-to-toe physical assessment Documentation of patient counseling/education Recommended treatment for new presentation of hypertension Copyright 2009 Vermont Information Technology Leaders, Inc Established patient travelling to Africa (immunizations required)
40 year old male, works for International Corporation, travels often, recently returned from a trip to South America PMH: HTN, impotence, depression, OCD HPI: Diarrhea since returning from last trip Medications: Documentation of vital signs, height, weight Documentation of head-to-toe physical assessment Verification of immunization requirements before trip to Africa Documentation of patient counseling/education Copyright 2009 Vermont Information Technology Leaders, Inc Well Woman Exam, Complex
55 year old female, divorced, 1 son, 2 grandchildren, works as a store cashier; no insurance; Ladies First for this exam; non-compliant with meds because she cannot afford them; does not understand process for applying for state insurance PMH: HTN, dyslipidemia, depression Medications HPI: Review of labs recently drawn one week prior to this visit EHR must demonstrate: Documentation of vital signs, height, weight Documentation of head-to-toe physical assessment Documentation of patient counseling/education Assistance with state insurance applications (link to webpage or pther info) Referral to social work or other assistance with living situation Copyright 2009 Vermont Information Technology Leaders, Inc # 6 Suboxone Patient (Opiate drug use treatment)

23 year old male, smoker, single, 6 months into the program, Medicaid, unemployed, weekly appt.,
counseling, AA meetings currently taking Suboxone.
PMH: Opiate drug use, various “street drugs”, alcohol use, and depression.
Medications:
HPI: C/O Anxiety regarding job search, problems regarding relationship with girl friend, hard to find transportation to get this office weekly for fol ow ups and script. EHR must demonstrate: 1. Obtain supervised urine sample and prepare it for shipment to out of state lab. 2. Review any current problems 3. Vital signs, ht and weight. 4. Physical assessment 5. New script 6. Return visit Copyright 2009 Vermont Information Technology Leaders, Inc

Source: http://www.vitl.net/sites/default/files/documents/EHR/form_7_clinical_scenarios_-_family_practice.pdf

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