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Brookside pediatrics and adolescent medicinescenario 1:

1. Well child scenario with complication
Female child 18 months old, here with mother for well child exam, including immunizations. The patient’s mother tells the front desk that there is a court order prohibiting the father to have any contact with the child or any access to the patient’s medical information. The front desk registrar notes this in the patient’s electronic chart. The mother also informs the registrar that she has moved and provides the new address and phone number which the registrar updates in the system. Her older son is also a patient at the practice and lives with the mother, although he has a different last name than the patient. Demonstrate how updating the patient address automatically updates the sibling demographics, although the last names are different. The system notifies the registrar that there is a $10 co-pay which is collected and entered into the system and a receipt prints out and is given to the mother. The nurse rooms the patient and mother, and documents the reason for the visit. The mother notes that the patient has seemed listless and has been crying more frequently for the last 2 days. The patient is not taking any medications. The nurse reviews allergies. The system shows that the patient is allergic to penicillin, but there is not documentation of the reaction. The reaction is a rash, and the nurse documents this. Patient’s vitals are: ________________. The nurse enters the patient vital signs into the system along with a two to three line text re the nature of the listlessness. The visit form changes to a sick visit with templates reflecting the presenting complaint. A pop-up notifies the front desk that the visit has changed from a well to a sick visit. The physician comes in and sees the patient. The physician does a physical exam in which it’s discovered that the patient’s throat is red and has white patches. Physician then documents the exam within the system, noting that all systems are normal: except throat. . The physician orders rapid strep culture on patient. This order is communicated electronically to the nurse. She acknowledges the order, performs the test, and documents the result in the system. The test is positive. The physician is electronically notified of the tests result, reviews and signs off. The physician then uses the e-prescribing module to order an antibiotic (choosing from a list which is a reflection of the diagnosis entered in the sick visit also could allow the physician to choose “not on the list” and add a choice on the fly). Demonstrate pediatric dosing calculations. Allow the physician to review past hx of strep infections as a popup or separate window. The antibiotic that the physician selects _______, is not on the patient’s insurance formulary, and the system notifies the physician of this. The physician selects another drug ______, which prescription is electronically transmitted to the patient’s pharmacy. Copyright 2009 Vermont Information Technology Leaders, Inc. Because the child is ill and the physician doesn’t feel comfortable giving immunizations when baby is sick he ends the visit and asks the mother to stop at the front desk to reschedule the well visit and immunization. He asks the mother to call the office in three days with an update on the patient’s condition. That phone note should be added as an addendum to this note. The mother and patient check out, making an appointment for 2 weeks in the future for the well visit and the immunization. The mother and patient return in 2 weeks. The patient has responded well to the antibiotic. The physician proceeds thru the well exam and orders the immunizations. An automated task is sent to the nurse, requesting administration of the immunizations. The physician gives the mother education materials regarding the immunizations and possible side effects The nurse comes in and administers the vaccines. She documents this in the system, noting the manufacturer, lot number and expiration date of the vaccines which have been stored previously in the system automatically populate the appropriate fields. This information is automatically transmitted to the state immunization registry. 2. Sick child visit for an asthmatic patient.
The practice receives a call from the father of a six year old male patient who is has a two day history of exacerbation of chronic asthma. The father states that for the past 2 days the patient has needed to use a rescue inhaler an average of five times/day, and requests an appointment within the next 2 days. The practice has 2 emergent slots remaining for today and the patient is scheduled for a visit. The patient arrives accompanied by his 22 year old cousin. The cousin explains that the patient’s parent has previously signed a consent form for her to bring child to the Dr. The registrar calls up the consent document which has previously been scanned, and reviews it. The cousin states that the patient has new insurance information which the registrar enters into the system. The registrar also scans the insurance card. The patient is roomed and seen by the nurse who evaluates the patient and documents the chief complaint, and vital signs. A peak flow test is done. (with bad results). Results are documented and automatically recorded on an Asthma Action Plan which prints out for the school. An SPO2 is obtained and recorded. (88%). The patient’s current medications are Albuteral and Advair _______dose. The physician sees the patient and reviews the patient’s medications and the course of his asthma, and examines the patient, documenting inspiratory and expiratory wheeze. The physician determines a nebulizer treatment is needed and orders this treatment. This order is communicated to the nurse. Copyright 2009 Vermont Information Technology Leaders, Inc. The nurse escorts the patient to the treatment room and administers the treatment, documenting the procedure in the system. Following the treatment, the nurse administers a second peak flow test and SP02, which shows improved results. The physician is notified of the results, and the patient is moved back to the exam room. The physician sees the patient, reviews post treatment vitals and reassesses lung sounds. and feels that the patient would benefit from a trial of ______ , (Insurance eligibility check) he prescribes this electronically. The physician then completes the visit note and the system suggests an E&M code based on the documentation. The physician agrees with the code and a visit charge (including the procedure charge) is generated. The physician gives the patient instructions on asthma control, and instructs the patient’s cousin as well. The physician requests that the patient return for a three month follow up visit. The patient and his cousin stop at the reception desk on their way out. The discharge coordinator schedules the three month follow up. 3. Annual exam for an overweight adolescent patient.
15 year old girl arrives with her mother for an annual exam, including pap. Mom stays in the waiting room while the patient is roomed. The nurse notes the reason for the visit and takes vital signs including weight. The patient weighs 155 lbs and is 60 inches tall. The system automatically calculates the patients BMI, and displays a warning that the patient is overweight. The physician comes in to perform the exam. The nurse remains present and documents in the system that she is the patient’s chaperone for this exam. The physician asks the patient if she is sexually active, and the patient assents. The exam is ordered, including pap, KOH, GC and Chlamydia. The order is electronically transmitted to the hospital lab. Specimens are collected and collection is documented. The physician asks the patient if she is using birth control and if she wants counseling re STDs. The patient assents, and the physician notes a referral to Planned Parenthood, also giving the patient the contact information for PP. After 5 days the lab results are received electronically from the hospital and the physician is notifies of the pending results. All results normal except Chlamydia is positive. Physician reviews the results and enters task in the system for nurse to call patient for return visit ASAP, and also orders __________ (drug). He then requests the system to general a normal pap patient letter and signs it. Copyright 2009 Vermont Information Technology Leaders, Inc. The STD is reportable to the public health department. Can the system communicate this electronically? If not, the physician enters as task for the medical records staff to report the disease. 4. Nine year old patient with ADHD here for a med check.
Patient arrives with his mother and they are roomed by the nurse. The nurse takes vitals, BP = 100/60, Pulse 75, Weight 60 lb, Height = 42 inches. Calculate the BMI and plot a growth chart for the patient. The historic view of the weight for this patient shows that he has lost 3 lbs since his last appointment 3 months ago. Nurse verifies meds. The mother confirms that he still taking 18mg of Concerta, and not taking his 5 mg of Ritalin (as of 2 weeks ago). She informs the physician that her son is not taking the Ritalin because it upsets his stomach. The nurse notes this in the chart. She also confirms that the patient has no known allergies. The physician sees the patient and does a review of systems. All systems are normal. The physician then documents the complete exam for the patient. In the discussion with the mother regarding the patient’s previous behavior issues, she indicates that his teacher has reported escalating behavioral incidents in classroom. The physician documents this information to the chart. The physician electronically prescribes a trial of Adderall. (dose) Prior authorization is required for this medication and the system notifies the physician, who enters a task for the front desk to obtain the authorization. The physician documents that he has advised the mother that her son should be getting a very good breakfast – and to add a snack right before bedtime because he has lost weight in the last 3 months. The physician prints out a patient handout for the mother that she is to give to the teacher that will allow him to assess the behavior in the classroom. The patient broke his right arm two months ago and it is healing well. The physician reviews a consult letter from the orthopod that he has received electronically, indicating that the fracture has healed and there is no follow up needed. The physician asks the mother to make a three month follow up appointment for an additional med check and to call if there are any adverse reactions to the medication. The mother and patient leave, and the physician completes the visit documentation, indicating the visit type and level of care. The system suggests an E&M code, which the physician accepts. A visit charge is generated. Three days later, the patient’s mother calls and says that the patient is having a reaction to the Adderall. The front desk enters this information as a task for the physician. The physician receives the task, calls the patients mother and asks that the medication be stopped. He d/c it in the system and orders another. All drugs are added to an Copyright 2009 Vermont Information Technology Leaders, Inc. automatically added to a timeline which can be popped up and reviewed for any patient who is being updated with an “ADHD med check” template. Copyright 2009 Vermont Information Technology Leaders, Inc.

Source: http://www.wakou.fr/sites/default/files/documents/EHR/form_8_clinical_scenarios_-_pediatrics.pdf

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