Knowledge Activity: Case Study Review (Associate)

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 (AS) 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 each tab in the EHR of Camille Wall, answer the questions below.

Questions
1. List the patient’s name and social security number (SSN).

The patient is Camille Wall and her is as follows SSN# 298-75-3892

2. At which service location did this patient receive care?

The patient received care at 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.

The address for the patient is 5847 Shoreview Dr Madison, WI 53532. The health plan
listed is Tricare Select and the patient is employed.

4. List any documented problems, along with the status and immediacy of each.

Osteoarthrosis, generalized, multiple sites / Status is active / Immediacy is Acute

 Pain in joint, lower leg / Status is active / immediacy is Acute

Backache, unspecified / Status Active / Immediacy is 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.

1. Lortab 10/500 (hydrocodone bitartrate / APAP) Oral Tablet / Dose 2 Tablets /

Route By Mouth / Frequency As Directed by PRN
2. Meperidine Hydrochloride 50 MG/ML injectable solution / Dose 50mg /route
Intravenous / Frequency Q2H
3. Promethazine Hydrochloride 25mg/ml injectable solution [Phenergan] / Dose 25mg /
Route intravenous / Frequency As directed PRN
4. 1ML diphenhydramine Hydrochloride 50 MG/ML Prefilled Syringe / Dose 25mg /
Route Intravenous / Frequency as directed PRN
5. Sodium Chloride 0.9% (Normal saline) (NaCI) / Dose 1000ml / Route Intravenous /
Frequency Continuous
6. 0.4 ML enoxaparin sodium 100 MG/ML Prefilled Syringe [Lovenox] / Dose 0.4mL /
Route Subcutaneous / Frequency Daily

7. What are the patient’s allergies and the reaction, if listed?

Adverse reaction/ allergy and the status is Active.

8. Does the patient have any Advance Directives documented in her EHR? If so, what are they?

No Advance Directives documented

9. List the patient’s most recent set of vital signs, including temperature, pulse, respiration, blood pressure, pulse
oximetry, and pain.

Temperature 98.8F / Pulse 82 / Respiration 16 / Blood Pressure 130/80 / Pulse Oximetry

93% / No pain

10. List the patient’s most recent lab values for HGB (hemoglobin), WBC (white blood cells) and Glucose found
under the Labs tab.

HGB 12.4 / WBC 10600 / Glucose 94

11. Was a consult order entered for the patient? If so, what type of consult was ordered? Who completed the
patient’s Admission Note?

Does not appear to have any consult orders / Cathy Rhoades, RN

 12. Does the Admission Note identify each of the problems listed from question #4? Identify which problems are
identified in the Admission Note and which are not.

Problems identified –

Osteoarthrosis, generalized, multiple sites / Status is active / Immediacy is Acute

Pain in joint, lower leg / Status is active / immediacy is Acute

Problems that were not identified

Backache, unspecified / Status Active / Immediacy is Acute

13. Who is listed as the physician who authored the patient’s Discharge Summary note? When is the patient due for
a follow-up visit?

Richard Chamberlain, MD / Two week follow up

14. What discrepancy exists between what is documented in the Discharge Summary note as the first listed
admission diagnosis versus what is documented under the Problems tab of the chart as the first listed admitting
diagnosis?

In the problem its noted as Osteoarthrosis and in the discharge, it’s noted as Degenerative Joint
disease.

15. Do you think this could cause confusion amongst the health care team? How could that be avoided?

Even though the terms are one in the same for documenting purposes I think the same
term needs to be used throughout the patient’s entire process from admission to
discharge. It could potentially cause confusion as degenerative joint disease I believe
means more than one thing. They need to be specific especially for billing purposes.
 Submit your work
Document your answers directly on this activity document as you complete the activity. When you are finished, save this activity
document to your device and upload this activity document with your answers to your Learning Management System (LMS). If
you have any questions about submitting your work to your LMS, please contact your instructor.

Learning objectives
1. Identify policies and strategies to achieve data integrity (3)