Knowledge Activity: Case Study Review (Baccalaureate)
Student instructions
1. If you have questions about this activity, please contact your
instructor for assistance.
2. You will review the chart of Camille Wall to complete this
activity. Your instructor has provided you with a link to the
Case Study Review (BS) activity. Click on 2: Launch EHR to
review the patient chart and begin this activity.
3. Refer to the patient chart and any suggested resources to
complete this activity.
4. Document your answers directly on this activity document as
you complete the activity. When you are finished, you will save
this activity document to your device and upload this activity
document with your answers to your Learning Management
System (LMS).
The activity
This activity is a detailed case study review, or audit, of a chart and its
contents. The activity provides an overview of documentation review
in an electronic health record, and an introduction to how the
diagnosis is supported through documentation, the patient’s progress,
clinical findings, and discharge status. After launching and thoroughly
reviewing teach tab in the EHR of Camille Wall, answer the questions
below.
Questions
1. List the patient’s name and social security number (SSN). Camille
1
, wall, 298-75-3892
2. At which service location did this patient receive care? General
hospital
3. What is the patient’s address, employment information,
and listed insurance plan name? Be sure to review all areas
of the patient’s EHR when searching for this information,
including the patient’s notes documented on the Notes tab.
• 5847 Shoreview Dr, Madison WI,53532
• Tricare
• Airforce
4. List any documented problems, along with the status and
immediacy of each.
• Osteoarthrosis, generalized, multiple sites, active, acute
• Pain in joint, lower leg, active, acute
• Backache, unspecified. Active, acute
5. List the procedure the patient recently underwent.
• Right total knee arthroplasty.
6. List the patient’s medication orders and their dose, route, and
frequency.
2
Student instructions
1. If you have questions about this activity, please contact your
instructor for assistance.
2. You will review the chart of Camille Wall to complete this
activity. Your instructor has provided you with a link to the
Case Study Review (BS) activity. Click on 2: Launch EHR to
review the patient chart and begin this activity.
3. Refer to the patient chart and any suggested resources to
complete this activity.
4. Document your answers directly on this activity document as
you complete the activity. When you are finished, you will save
this activity document to your device and upload this activity
document with your answers to your Learning Management
System (LMS).
The activity
This activity is a detailed case study review, or audit, of a chart and its
contents. The activity provides an overview of documentation review
in an electronic health record, and an introduction to how the
diagnosis is supported through documentation, the patient’s progress,
clinical findings, and discharge status. After launching and thoroughly
reviewing teach tab in the EHR of Camille Wall, answer the questions
below.
Questions
1. List the patient’s name and social security number (SSN). Camille
1
, wall, 298-75-3892
2. At which service location did this patient receive care? General
hospital
3. What is the patient’s address, employment information,
and listed insurance plan name? Be sure to review all areas
of the patient’s EHR when searching for this information,
including the patient’s notes documented on the Notes tab.
• 5847 Shoreview Dr, Madison WI,53532
• Tricare
• Airforce
4. List any documented problems, along with the status and
immediacy of each.
• Osteoarthrosis, generalized, multiple sites, active, acute
• Pain in joint, lower leg, active, acute
• Backache, unspecified. Active, acute
5. List the procedure the patient recently underwent.
• Right total knee arthroplasty.
6. List the patient’s medication orders and their dose, route, and
frequency.
2
