Documenting a Patient Phone Call for a Electronic Health Record

This is a paper that focuses on Documenting a Patient Phone Call for a Electronic Health Record. The paper also provides framework on writing the report for the system.

Documenting a Patient Phone Call for a Electronic Health Record

Learning objectives
Firstly, demonstrate professional transcription skills when documenting in an Electronic Health Record (EHR).
Secondly, document accurately in the patient record.*
Structure, Organize, and Prioritize interview data into a professional note in the patient’s electronic health record.
Thirdly, analyze communications in providing appropriate responses/feedback.*
Then, advocate on behalf of patients.*
Fourthly, apply current knowledge of electronic health records and appropriate, accurate documentation.
Lastly, demonstrate telephone techniques* (if completed in lab setting).

*Directly maps to MAERB educational competencies.

Student instructions
1.     If you have questions about this activity, please contact your instructor for assistance.
2.     You will review the chart of Alec Allard to complete this activity. Additionally, your instructor has provided you with a link to the Documenting a Patient Phone Call activity. Click on 2: Launch EHR to review the patient chart and begin this activity.

However, refer to the patient chart and any suggested resources to complete this activity.
You will complete documentation in EHR Go as instructed below. Subsequently, when you complete this activity, you will download your Progress Report in EHR Go under 3: Download Work, save the Progress Report to your device, and then upload the Progress Report to your Learning Management System (LMS).

The activity

Firstly, launch the EHR and review Alec Allard’s EHR, specifically in the Notes, Vitals, and Orders Tabs. Then read through the telephone call transcript in this document.

In the EHR, go to the Notes tab and click on the New button in the bottom right of the screen. Select the Free Text Note template. For date and time, click into the box to change the date to tomorrow and the time to 0900. Leave yourself as the author and choose the Central Clinic as the location.

See below for an example of the correct selections in the Note Choice box.