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Patient Presentation Medical Template

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Patient Portal Template

Transcript: Patient Portal Utilization Meaningful use is using certified electronic health record (EHR) technology to: Improve quality, safety, efficiency, and reduce health disparities Engage patients and family Improve care coordination, and population and public health Maintain privacy and security of patient health information Meaningful use sets specific objectives that eligible professionals (EPs) and hospitals must achieve to qualify for Centers for Medicare & Medicaid Services (CMS) Incentive Programs. Two metrics: Patient Electronic Access 1: 50% target Measure 1: More than 50 percent of all unique patients seen by the EP during the EHR reporting period are provided timely access to view online, download, and transmit to a third party their health information subject to the EP's discretion to withhold certain information. Patient Electronic Access 2: 5% target For an EHR reporting period in 2017, more than 5 percent of unique patients seen by the EP during the EHR reporting period (or his or her authorized representatives) view, download or transmit to a third party their health information during the EHR reporting period. “When patients interact with their test results, they need to know the purpose of the test, the interpretation of the result, and next steps. Addressing these issues may help improve patient-centered care” (Baldwin, Singh, Sittig, & Giardina, 2016). References 2016 Program Requirements. Retrieved September 25, 2016, from Baldwin, J. L., Singh, H., Sittig, D. F., & Giardina, T. D. (2016, October). Patient portals and health apps: Pitfalls, promises, and what one might learn from the other. In Healthcare. Elsevier. Eschler, J., Liu, L. S., Vizer, L. M., McClure, J. B., Lozano, P., Pratt, W., & Ralston, J. D. (2015). Designing Asynchronous Communication Tools for Optimization of Patient-Clinician Coordination. In AMIA Annual Symposium Proceedings (Vol. 2015, p. 543). American Medical Informatics Association. Heyworth, L., Paquin, A. M., Clark, J., Kamenker, V., Stewart, M., Martin, T., & Simon, S. R. (2014). Engaging patients in medication reconciliation via a patient portal following hospital discharge. Journal of the American Medical Informatics Association, 21(e1), e157-e162. Snyder, E., & Oliver, J. (2014). Evidence based strategies for attesting to Meaningful Use of electronic health records: An integrative review. Available in the. Online Journal of Nursing Informatics (OJNI), 18(3). Wade-Vuturo, A. E., Mayberry, L. S., & Osborn, C. Y. (2013). Secure messaging and diabetes management: experiences and perspectives of patient portal users. Journal of the American Medical Informatics Association, 20(3), 519-525. Wilcox, L., Patel, R., Back, A., Czerwinski, M., Gorman, P., Horvitz, E., & Pratt, W. (2013, April). Patient-clinician communication: the roadmap for HCI. In CHI'13 Extended Abstracts on Human Factors in Computing Systems (pp. 3291-3294). ACM. Stage 3 and MACRA Meaningful Use and the Patient Portal Literature “regular internet use and having a personal computer partially accounted for differences in use of the portal to send messages to health care providers by age, race, and income, whereas education and sex-related differences remained statistically significant even after controlling for internet access and care preference” (Graetz, Gordon, Fung, Hamity, & Reed, 2016). Meaningful Use Usability and Functionality Wanjiku Kariuki Viola B. Leal Mohammad Tabatabai Ana Ibarra Noriega Secure Messaging “over two-thirds had at least one medication discrepancy at discharge, and nearly one-third had at least one potential ADE” (Heyworth et al., 2014). The authors found that “virtual medication reconciliation following hospital discharge has the potential to improve medication safety in the transition from inpatient to outpatient care” “more effort on the part of the provider is needed to encourage patients to use a portal system. If providers take a more active role in educating patients as to the benefit of the portal, provide a positive view of the system, provide consistent standardized information, and remind the patients in multiple ways and times, patients are more likely to enroll in the portal system” (Snyder & Oliver, 2014). Objective 8: Patient Electronic Access (VDT) Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the EP. Patient Portal Metric Provider Buy-in Portal on Newer Internet Browser Lab Test Results DMC Patient Portal “patient and provider attitudes toward patient portal use found that the most negatively-perceived feature was user-friendliness, making the portal difficult to navigate” (Baldwin, Singh, Sittig, & Giardina, 2016). “When patients interact with their test results, they need to know the purpose of the test, the interpretation of the

Patient Assessment: Medical

Transcript: Suspect Pancreatitis Dependent Edema: A buildup of fluids in the extremities. Lower Mid-Abdomen Pain (Retropubic) Body Cellulitis: Cells are inflamed by infection and appears red and swollen Diverticulitis should be suspected. Stroke Cold, Clammy Skin Rash indicates irritation of the skin that can be caused by bacteria, fungi, virus, or allergen, but is very rarely life threatening. Suspect a kidney infection. This can be life threatening. Both present with pain anywhere in the abdomen. Heart and Aorta Hypoglycemia Vomiting Sharp Abdominal Pain Radiating to the Back Suspect cystitis Patient Assessment: Medical Costovertebral Angle Pain Tumor Indicates inadequate perfusion and circulation. This could indicate a more serious issue such as CHF, shock or hypoxia. Urinary Tract Infection (UTI) Extremities Urinary Tract Infection (UTI) Could be from an imbalance in intestinal bacteria, food poisoning, or another illness. If the stool is bloody, there is hemorrhage in the anus, rectum or lower intestinal tract. If it looks like coffee grounds, suspect upper intestinal bleeding. Esophageal Varrices Abdomen Green Sputum Shortness of breath indicates inadequate oxygenation which could be due to inadequate blood flow from the heart or or the lungs aren't getting enough oxygen. Seizure Medical issues in the thoracic cavity involve primarily the heart and lungs. Lungs are affected by an immune response, while the heart health is usually put at risk by chronic health problems such as high blood pressure, atherosclerosis, and blood clots. Gallstones Kehr's sign appearing on the left side indicates significant irritation of the spleen Pneumonia Coughing up green sputum indicates an infection in the lungs. This is a strong indicator of a ruptured descending aortic aneurysm. Head Deep Vein Thrombosis: A deep clot that will most likely cause swelling. Lungs Petit mal Grand mal Partial Tonic clonic Status epilepticus Patient is mostly sick or poisoned, and the patient is trying to get it out. If "coffee grounds" are coming up, expect internal bleeding in the stomach. Kidney Infection Kidney Stones Hernia and Peritonitis Most likely asthma. Diarrhea Abdominal Pain with left Shoulder Pain Possibly an ulcer Can present with severe bleeding that will come out of the mouth and run down the throat into the stomach. Mid-Abdomen Pain Transient Ischemic Attack (TIA) Wheezing Rash LLQ Abdominal Pain Kehr's sign on the right side indicates cholecystitis. If an unpleasant smell is also present, it it likely ruptured. May cause altered mental status and/or seizures. Crushing chest pain indicates myocardial infarction. Sharp chest pain Strokes consist of lack of blood flow to the brain. They may be ischemic (occluded artery) or ruptured aneurysm (hemorrhage) RUQ Abdominal Pain with Pain in the Right Shoulder Swollen Limbs LUQ and RUQ Pain Patient may present with altered mental status. Infection in the lungs that presents with green, thick sputum. Thoracic Cavity Headache

patient medical report

Transcript: High blood sugar levels means that your already at risk for devloping a heart disease or diabetes -the fatty deposits increases buildup in the arteries and narrow them Smoking can lead to cancer,lung disease,heart disease and numerous health problems Nutritionist/dieticians Ramon jordana smokes a pipe occasionally which is just as risky as cigarettes Being overweight can lead to numerous health problems such as high blood pressure, stroke,certain cancers, heart disease, etc. Goal:less than 100 mg/DL A Cardiologist can help Ramon diagnose his current or possible heart problems by running tests such as ECG, x-ray and blood tests.they can help determine if heart conditions are in Ramon's genetic lineage Actions to lose weight EATING HEALTHY &PHYSICAL ACTIVITY = LOSING WEIGHT Ramon has a very high LDL and low HDL Patient #4- Ramon Jordana Control blood sugar A physical trainer helps people of all ages and fitness levels to safely improve their physical condition through exercise and proper diet. Reduce blood sugar levels by: Eat foods low in sat fats, trans fat, &cholesterol A Cardiologist is a doctor with special training and skill in finding, treating and preventing diseases of the heart and blood vessels. Cardiologist They can help ramon plan meals that limit fats and sugar. help with healthy eating habits and diagnose nutrition issues. If Ramon continues with a healthy diet and exercise with prescribed medicine he can avoid the risk of having a heart attack MANAGE CHOLESTEROL attending local support groups/ programs use therapy, such as nicotine patch and gum take mind off smoking(traveling, eating a snack, deep breaths) get prescription medicine from doctor lose weight follow healthy diet regular physical activity take prescribed medicine Give up smoking Goal: lose 10% of body fat change diet lose weight take medicines eat more HDL Dietitians and nutritionists evaluate the health of their clients. based on the patient, dietitians and nutritionists advise clients on which foods to eat—and those foods to avoid—to improve their health. A physical trainer can help Ramon to lose weight by exercising properly. Ramon is in a wheelchair basketball league THE END RESULT Medical Information: 196 pounds 115-158 Blood pressure :120/71 Cholesterol:190 LDL:100 HDL:39 Tryglycerides:75 60 year old male that smokes weighs 196 pounds and is 5'7 in a wheel chair since he was 18 years old he is changing his diet instead of taking prescribed medicines Physical trainer Actions to give up smoking:

Medical Patient Assessment

Transcript: Dispatch Info Airway Breathing Circulation Disability - transport decision Exposure load & go critical patient that needs immediate tx & transport patient's general health? childhood diseases? recent hospitalizations? trauma? onset? anything make it better, or worse? how does breathing feel? severity? continuous, or intermittent? PASTE What substance involved When did this occur? Duration? How much ingested, exposed to, etc? MSDS, poison control, HazMat info? Decon needed? Any interventions? Patient weight? SAMPLE OPQRST page 609-611 GI/UI Other? page 730 Reassess Radio Report Vitals SAMPLE OPQRST Psychiatric/Behavioral Cardiac stay & play non-critical patient Bleeding? Amount of blood loss? Pain? Medications? Last menstrual activity? likelihood of pregnancy? discharge? urinary issues? bowel problems? nausea or vomiting? Medical Assessment previous heart attack? heart problems? angina heart failure hypertension? respiratory issues? CAD? diabetes? risk factors? family history? OPQRST interventions PTA? epi-pen available? MDI? SOB? respiratory issues? itching, rash, hives, swelling? previous hospitalizations for asthma, allergy? last oral intake? previous allergic Hx? SAMPLE - OPQRST page 540-541 Progression? Associated Cx Pn? Sputum? Talking Tiredness? Exercise Tolerance? page 580-583 Endocrine or Blood Do you take medications for diabetes? When was your last dose? Have you eaten normally today? Any illness or unusual activities? PMH? AMS? Respiratory PASTE page 677-678 page 628 BSI Give me 5 Scene Safety NOI # of patients ALS? C-spine Good Looking Chicks General Impression LOC C/C Gynecological Allergic - Anaphylactic Interventions Secondary Survey Not Sick environmental trauma assault HazMat MCI _________________________ _________________________ _________________________ Skin Pulse Respirations BP Pupils Lungs O2 Sat CBG AMS/LOC? - GCS Onset? Stroke Scale? History of Heart Disease? History of Seizures? Diabetes? Trauma? Medications? Toxicology? ????? Toxicology Sick? page 705-706 page 496 OPA, NPA, head-tilt, etc Oxygen, BVM, etc Supine C-Spine Glucose, other meds Transport Restraints etc _____________? Neuro issues drugs, medications, toxins psychogenic or OBS? Family/friends information AMS competent? oriented to time, place, person, event(s)? ABCDE page 652 Neuro Nausea &/or vomiting? changes in BMs? Urination issues? weight loss? belching, flatulence, bloating? Pain? OPQRST Bleeding? Other????? Chest pain? AMS? SOB? OB/Gyn issues?

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