Student Resources

EMR Links


Medical References

UpToDate 

Clinical Key (Formerly MD Consult and First Consult)

Micromedex (Drug reference)

Diagnosaurus (Differential Diagnoses)


EMR Instructions for Students

The content you enter into the EMR constitutes legal documentation. Take care to ensure that the information recorded in the EMR matches the paper charts. 

 

1) Search for your patient by last name.

2) Click the icon in ‘Patient Chart’

3) Click on today’s visit.

 

Note: For all form fields, once a note has been typed, always check the ‘Verified’ box.

 

4) Subjective

  • History of Present Illness: Put a brief summary of the patient’s condition today and history of symptoms.
  • Past Medical History: Put any significant Medical History. Bullet points are fine. 
  • Immunizations: Put any Immunizations given today, including Lot # and Exp Date (from consent form)
  • Risk Factors: If the patient has had any significant IV Drug/ETOH/Tobacco use

 

5) Medications and Allergies

  • Edit medications
    • Search (Light Blue Box): Search for the drug by entering the first few letters, then hitting ‘Drug Search’. Try to find the proper drug, dosage and method of entry. Click the drug.
    • Doctor (if known)
    • Search for drug and dose
    • Sig: Any additional notes/information you want listed. If it is a drug we are dispensing, type "Samples given" in this field.
  • Once all drugs have been added, select all drugs by clicking on the check box and then do “Select to move to current meds” so that all of the drugs go into “Current Medications for PATIENT NAME”
  • Allergy/Intolerance: search for allergy if not listed in the common allergies
    • When searching, search and then see if it is listed in the drop down menu right below the search field, choose the allergy, and then select the severity. These will be automatically entered, NO NEED TO CLICK AND DO A SELECT TO MOVE TO step here
  • Medication Reconciliation Completed: MAKE SURE THIS IS CHECKED WHEN YOU ARE DONE WITH MEDS/ALLERGIES

 

6) Review of Systems

  • type “npe…” without the quotes and the pre-filled normal physical exam template will automatically be inserted
  • REVIEW THE TEXT! Delete anything you did not check during your exam and replace text with any abnormal findings (ex. If you did not listen for carotid bruits, delete that text from the heart exam.)

 

7) Objective Data

  • Vital signs

 

8) Assessment

  • Problems Search
    • Search for the problem/diagnosis/complaint of the patient. It is not dependent on the type of problem selected above. Examples of common items: Fatigue, Back Pain, Urethral Discharge, Systolic Hypertension, Pregnancy Test
  • Find a precise diagnosis
  • Status is important - Even if someone is in for a follow up, select what they are following up for, and say it’s resolved in the status

 

  • New Problems: ‘Add New”
    • Problem Type: If there was any diagnosis or significant finding on history/exam (ex: Chronic Hep C, or lipoma) select ‘Diagnosis’ or ‘Finding’. Otherwise, select ‘Complaint’. 
    • If the patient came in for a physical and there were no issues, select ‘No Problem Found’ and then in the comments box, put down something like ‘Work physical, no problems found’ or ‘Preventive: PAP Smear’ in the comments.
    • Status: Select ‘Active’, ‘Intermittent’ or ‘Inactive’
  • Comment: Enter any pertinent comments. If you selected ‘No Problem Found’, put the reason in here.

 

9) Plan

  • Plan of care (free text) Put a brief summary of any exams/tests taken today, the plan to treat any problems listed in the Assessment, and any medications given. (Be sure to use the word ‘samples’ when describing any meds given). If the patient needs to return or have anything done on next visit, make sure to note that.
  • Sign chart, LOGOFF AND CLOSE PHSCONNECT!!!