Download Date Time

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ICIS
Proposal Validation Session
Clinical Scenario
Please use the following information to build the clinical scenario for demonstration purposes. Three forms that we
currently use for documentation are also included. The forms have been scanned and are best viewed in a printed
format. The Scenario Evaluation Tool clearly indicates the functions that should be demonstrated during the
scenario session. Additional information will be given on site for real-time data entry.
Ms Apple, 16 year-old Gravida II, Para 0, Abortion 1; lives in Fayette County. On her first
______ Obstetrics (OB) clinic visit, the clerk notes the patient has not previously been seen in
the ________ Healthcare system. The patient is registered as a new patient.
Registration Information:
Date Time:
Angela Jane Apple
DOB 10/30/82
Single
No insurance
Address:
Phone: home
Guarantor: Mother:
Home phone work
Chief complaint: pregnancy screening visit
Primary care physician:
Nurses note (Jane Jones RN): Urine pregnancy test positive at Health Dept 9/8/99. LMP
8/98. Referred by Dr. Peach. Wt.61kg. B/P 120/72, P 68, RR 16 T98.4 Allergies: PCN.
OB Physicians Note (Dr. Brown): Normal pregnancy exam. Prior suicide attempt at age
12, parents divorced. Hgb 10
Problem list: Anemia, Depression, and Confirmed Pregnancy
Prescription: Mulitvitamin 1 qd, Slow Fe 1 qd
Ms. Apple presents to ______ Emergency Dept. (ED) Date 1/18/99
Presentation Time: 0840
DOB 10/30/82
Mode of arrival: walked
Triage note entered at 0842 by
VS: B/P 136/80, T 99oral, P88, RR 16
Wt 145 lb
LMP Aug 98.
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Chief complaint: urine infection
Triage hx: c/o frequency and burning upon urination x 2 days. Lt lower back pain.
Pregnant.
Tx prior to arrival: none
Last MD visit: OB clinic 9/04/98
Meds: prenatal vitamins and iron
Allergies: PCN
Acuity 3
Triage completed at 0850
Registration: Data update: Ms Apple has gotten married and is now Mrs. Orange. She
lives at ___________________, phone _________. Her guarantor is her husband
________, 18 y.o. who works part time at _________. They have no insurance.
Placed in treatment room at 0900
Nursing Assessment (Amy Blue RN): Skin warm and dry, pink mucous membranes.
Denies nausea and vomiting. Urine appears slightly blood-tinged, hx of UTI’s in the past.
No hx of pylenephritis. Denies any constipation or diarrhea. Denies alcohol, tobacco use
or other substance abuse.
Nursing Diagnosis: Infection, High Risk
Nursing Interventions ordered: clean catch U/A, explain all procedures
Nursing notes(Amy Blue RN): 0900 Undressed, instructed on clean catch urine. To
bathroom
0910: urine speciman obtained, cloudy. Physician at bedside.
0930 Discharged home with instructions for UTI and Bactrim. Verbalized understanding
of instructions Prescription given for bactrim. Discharged with mom at 0930. ED
charge Level 2.
Physician H & P(John Jones Resident): 16 y.o. gravida 2, para 0, abortion 1, 18 wks
gestation presents with burning upon urination, fever to 101 times two days. Review of
systems within normal limits. Family hx: recently married, mother diabetic. Physical
exam: unremarkable. Medications: multivitamin, Slow Fe Allergies PCN.
Urine dip: mod leukocytes, - nitrites, - bili, - protein, ph 7.0, trace blood, - ketones, glucose, specific gravity: 1.020. wbc 12,000.
Assessment UTI
Plan: Home, Bactrim I DS bid x 7 days, force fluids, tylenol for temp >101. Notify of
culture result. Follow-up in OB clinic if condition worsens.
Notify PCP and OB MD of this visit
Co- signed by ED attending, Chuck Grant MD.
4/19/99 Mrs. Orange presents to ______ Hospital OB triage at 36 weeks in questionable labor
that is confirmed.
Problem list from ED visit and OB clinic is retrieved. Transferred to Labor and Delivery
and placed on a Vaginal Delivery clinical pathway (See ICIS Images: Clinical Pathway 1
and 2. For demonstration purposes only the Admission, Recovery and Maintenance
Phase need to be displayed). The “Admission Phase” orders are: D51/2Normal Saline to
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run at keep open rate, NPO, check urine for protein on first void, hemogram, type and
hold 2 units packed cells, bedrest, fetal heart monitoring, and initiate L & D teaching
sheet. A social worker consult is ordered because the patient has no insurance.
During “Recovery Phase” of clinical pathway, Ms. Orange meets the outcome “Indicates
Desired Pain Relief”. Mrs. Orange delivers Baby Monica Amy. During the
“Maintenance Phase”, the nurse determines Mrs. Orange is not meeting the outcome
“Demonstrates Appropriate Bonding Behaviors”. The social worker (Mrs. Black)
consults with Mrs. Orange and enters consult note: Medicaid application completed.
Within 24 hours of admission to Postpartum, Mrs. Orange develops acute pulmonary
edema. She is transferred to the Coronary Care Unit (CCU) and the Cardiology service,
intubated, placed on a ventilator. A Swan Ganz catheter is inserted for fluid and
inotropic management. The nurse documents hemodynamic parameters (pulmonary
artery pressures, cardiac output, cardiac index) (See ICIS images ICU flowsheet )
Vital signs in ICU
4/20
0400 0500 0600 0700 4/21
Temp
99F 99.4 99.6 99.2
HR
130
128
130
110
BP
140/85 136/80 140/84 130/80
RR
32
30
30
28
CO
4.0
4.0
5.4
CI
2.0
2.0
2.5
CVP
19
18
15
PCWP
18
16
14
PAS/PAD
35/20 36/14 22/16
SVR
1050 908
922
SpO2
95
95
96
97
ABG
Ph
PCO2
PO2
Os sat
HCO3
Base Excess
0400
7.30
32
86
96
18
-1.0
Glu
BUN
Cr
NA
K
Cl
CO2
Mg
180
38
1.0
138
3.2
105
26
1.4
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0600
7.32
35
92
97
20
0.5
150
40
1.2
142
4.5
105
22
1.4
0700
4/21
0600
98.2
100
122/80
24
5.7
2.8
14
12
36/14
932
98
0600
145
42
1.4
142
4.4
106
24
1.4
4
WBC
RBC
Hgb
Hct
Platelets
10.5
4.3
9.2
30
138
12.1
4.0
9.6
31
148
The nurse documents a shift assessment at 0400. (The data for the Circulation section of
shift assessment note will be given to you on-site, see ICIS Images:ICU/Acute Care
Flowsheet for current note format)
Respiratory : Respirations regular, breath sounds crackles in both bases, requires
suctioning OETT, Secretions clear, thin, white. OETT,
Gastrointestinal/Renal: Abdomen soft, Bowel sounds: hypoactive, Stool: Last BM:
enema 4/19, Diet: NPO, Renal: foley, Urine: cloudy, sediment, yellow
Immobilization: N/A
The admitting resident was called away to another patient’s code before he could write
the admit note (delayed charting) (The Cardiology admit note will be given to you on site
for data entry). Mrs. Orange has an echocardiogram, an arterial blood gas, 2 hemogram
panels (hemoglobin, hematocrit, WBC, RBC, platelets) and 3 electrolyte panels (sodium,
potassium, chloride, CO2, BUN, creatinine, magnesium) during the first 24 hours in the
CCU. Mrs. Orange is started on Captopril 12.5 mg PO TID.
On 4/21 the Resident physician enters his progress note (The Resident progress note will
be given to you on-site for data entry).
When Mrs. Orange’s condition stabilizes, she is transferred to a telemetry floor. Her K+
is 4.2 and Creatinine is 1.0 the day after transfer. Captopril is increased to 25 mg PO TID.
Two days later, the MD orders lisinopril 5 mg PO BID. The captopril is not d/c’d. The
ordering MD is notified of duplication from same drug category.
4/30/99 Mrs.Orange.
is discharged. Per physician request the clerk checks the system for
back –to –back f/u appointments on the same day for ______ OB clinic with Dr. Brown
and _____ Cardiology clinic with Dr. Peyton are ordered in 1 month, first available in the
afternoon.
The discharge is entered:
Date of Birth 10/30/82
Admit Date: 4/19/99
Discharge Date 4/30/99
Discharge Physician:
Admit Diagnosis: Labor
Discharge Diagnoses/Problem List: Anemia
Depression
Status post UTI
Status post Infection-High Risk
Uncomplicated vaginal delivery with live birth
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Acute Pulmonary Edema
Postpartum Cardiomyopathy
16 year old white female with history of anemia, depression (nonpharmacological
treatment only), UTI presented to _______ Hospital 36 weeks’ gestation in labor. Dr.
Brown had followed patient in _______ OB Clinic and Dr Peach in Harrodsburg.
Delivered 7lb 5 oz female infant without complication. Approximately 24 hours
postpartum, developed acute respiratory distress requiring intubation and mechanical
ventilation. Transferred to CCU where pulmonary artery catheter placed and inotropic
support and diuresis initiated. Hemodynamic parameters and oxygenation subsequently
improved. Successfully extubated after 36 hours on the ventilator to nasal cannula.
Tolerated ACE inhibitor therapy. Patient was transferred to telemetry monitoring for 3
days with continued improvement in hemodynamic status.
Discharged to home on the following medications: Captopril 25 mg PO BID, Lasix 20
mg PO QD, Slow Fe one tab QD and daily multivitamin. Follow-up with _______ OB
and Cardiology clinics in 2 weeks.
Dictating MD:
Attending MD:
5/12/99 At the OB clinic visit
The clinic nurse documents wt 110 lbs. BP 112/80 lying, 110/75 sitting, respiration even,
unlabored. HR 78, RR 16, T 98.4. her inpatient Vaginal Delivery clinical pathway is
reviewed and an electrolyte panel is obtained.
5/12/99 During the Cardiology clinic visit
________ reviews the patient’s problem list (anemia, depression, UTI, infection-high risk
, vaginal delivery, postpartum cardiomyopathy) from the discharge summary and trends
all labs obtained in the hospital and _____ OB clinic after discharge. Creatinine is 3.2.
The physician is prompted by a rule that suggests stopping ACE Inhibitors if Creat. > 3.0.
________ reviews the vital signs. _______ documents the plan for discontinuation of
ACE inhibitor and f/u appointment with him in 1month (The Outpatient clinic progress
note will be given on-site). _________ enters the diagnosis postpartum cardiomyopathy.
System suggests an appropriate level of service dependent upon documentation.
Show how to look up patient in enterprise master member and patient index
Show to register a new patient (Patient information will be provided on site for registration of
new patient).
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