Neehr Perfect Activity: Pathophysiology and
Pharmacology Case Review
Overview
This activity is intended for the Beginning, Intermediate or Advanced EHR student user. It is a detailed
review of a patient chart: problems, medical diagnosis, disease processes, treatments, medications and
labs. It utilizes critical thinking and the ability to do basic research.
Pre-requisites
1. Completion of Scavenger Hunts Levels I and II.
2. Completion of Scavenger Hunt Level III – Optional
3. Completion of Neehr Perfect EHR Activity: Using the Tools and Resources in Neehr Perfect
Student instructions
1. If you have questions about this activity, please contact your instructor for assistance.
2. Access the chart for Emily Carey.
3. Document your answers directly on this document. When you are finished, save this document
and upload it to your Learning Management System (LMS).
Resources that may be helpful
1. In the patient chart select the Tools Menu. In the Tools menu are valuable resources:
a. Drug Information Portal
b. Lab Tests Online
c. Health Information
2. Use your textbooks or reputable websites from the Internet.
Learning objectives
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Apply current knowledge of electronic health records and location of information.
Demonstrate the ability to filter and locate the correct chart.
Recognize necessary data based on location, date and/or details provided in the record.
Apply the resources available in the EHR.
Explain the pathophysiology of identified problems, medical diagnosis and medical procedures.
Explain the indications, contraindications, adverse reactions, routes and doses of identified
medications and treatments.
Demonstrate adequate interpretation of normal and abnormal vital signs.
Demonstrate adequate interpretation of normal and abnormal lab values.
Apply critical thinking skills.
Apply basic research skills.
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Neehr Perfect EHR Activity: Pathophysiology and Pharmacology Case Review v2
Archetype Innovations, LLC ©2016
The activity
In the hospital or clinic setting each patient has a medical record (electronic health record). The person’s
physician, nurse practitioner, or other provider will review the patient’s history, their current
condition(s) or problem(s), medications, treatments and diagnostics to develop a treatment plan. The
patient condition may be simple or complex, but requires a thorough review and understanding of the
conditions, medications, etc. Many professionals, no matter their length of experience, use resources to
gather information, double-check themselves, or see what is new in health care. This activity will get you
to think critically about the “whole” picture instead of just one problem or just one lab. You will use
resources available through the EHR and your own resources (textbooks, Internet).
Chart name and SS#: ____________________________
1. What is the patient’s age and sex?
2. Go to the Problems tab in the patient chart. List all of the problem(s), medical diagnosis(s), and
procedures, and the ICD9/10, CPT, or HCPCS code associated with the problem.
3. With each problem and medical diagnosis listed in question #2, explain the pathophysiology for
each.
4. For each medical procedure or surgery listed in #2, explain what the procedure is and why it
may have been done on this patient.
5. Go to the Meds tab (or the Orders tab). List all of the active medications. Include the dose, route
and frequency. If there are no medications listed on the Meds tab, go to the Orders tab to locate
the patient’s ordered medications.
6. For each medication listed in #5, list the following:
Brand name/Generic name.
Why this medication is typically prescribed.
Why the medication was prescribed to this patient.
Major side effects or precautions for the medication for this patient.
7. Go to the Cover Sheet tab. What are the patient’s allergies and the reaction for each? If none
are listed indicate “NKA”. For any medication allergies, list other medications – that if ordered –
would be contraindicated and need physician review.
8. From the Cover Sheet tab or the Reports tab locate the first set of vital signs (the earliest date
and time in the record). Include the height and weight. List them here. Identify any vital signs
that are out of normal range (high or low) and list the normal ranges based on this patient’s age
and/or sex.
9. To locate labs in a patient chart they will be in one of two places. In the Notes Tab documented
in a Lab Results Note. And/or on the Labs Tab of the chart. Locate the first lab values (the
earliest date and time in the record). Give the lab test and the value.
10. For any lab values in the chart that are identified as low or high in question #9, list the normal
value(s) for that lab. Based on the patient’s information (problems, diagnosis, medications,
vitals) explain why the lab value(s) are abnormal.
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Neehr Perfect EHR Activity: Pathophysiology and Pharmacology Case Review v2
Archetype Innovations, LLC ©2016
Submitting your work
Document your answers directly on this document as you complete the activity. When you are finished,
save this document and upload it to your Learning Management System (LMS). If you have any
questions about submitting your work to your LMS, please contact your instructor.
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Neehr Perfect EHR Activity: Pathophysiology and Pharmacology Case Review v2
Archetype Innovations, LLC ©2016