Answer Happy

This is a case of a patient with several chronic disease who
moves in and out of a health care facility as her symptoms got
worsen. Mrs. Habib is a 77-year old woman with four chronic
condition: diabetes, Congestive Heart Failure (CHF), Chronic
Obstructive Pulmonary disease (COPD), and Osteoporosis. She
has a Primary Care Physician (PCP) and see five other
specialists. She takes 15 prescription and non-prescription
medications. She has one emergency room visit, two
hospitalization and one observation stay in the last six
months. She has also had a hip replacement hospitalization
and a postop skilled nursing facility stay and two home care
episodes if care during this time period. Her family
caregivers are her 79-year old husband, who also has chronic
illness and her 50-year old daughter, who works full-time and has
two teenage children.
How do the various medical records tell the patient
story for this patient?
Care providers Hospital July to December • Two hospital inpatient stays for heart failure, one inpatient stay for hip replacement surgery, two ER visit for hearts failure, and one observation stay Emergency Room (ER) care coordinator notifies primary care physician For home discharge, care coordinator gives patient instructions and sends referral to home care agency Hospital arranges post- discharge primary care physician visits Medical record • Hospital sends electronic referrals to SNF and home care agency Hospital notifies the primary care physician of admissions and ER visits by phone call Hospital send the primary care physician the discharge summary for one inpatient stay Orthopedic surgeon Surgeon sees patient for one preoperative visit • Surgeon performs surgery Surgeon sees patient for two post operational visits • Orthopedic practice EMR, connected to hospital EMR patient portal Orthopedic office sends a paper report to PCP office Unit Nurse Patient has 15-day inpatient stay following hip replacement • Unit rounding physician manages medical care while patient is in the facility • Social worker coordinates discharge plan Unit nurse records on paper Discharge summary faxed to PCP office • Referral form faxed to home health agency PCP office Sees patient monthly PCP EMR is not connected to hospital EMR
PCP office . . . Sees patient monthly Saw patient for one post hospital visit Patient missed one scheduled post hospital visit . PCP EMR is not connected to hospital EMR No patient portal All instruction and information are given to the patient on paper Cardiologist Sees patient for three office visits and two hospital visits Cardiology connected EMR EMR hospital to Pulmonologist . Sees patient for one office visit and one hospital visit Pulmonology EMR connected to hospital EMR Patient portal 1 into practice EMR Pulmonologist does not communicate with PCP Gynecologist One preventive visit Gynecologist EMR uses patient portal 1 No communication with . PCP Endocrinologist . Sees patient for three office visits Endocrinology connected to records records hospital Pharmacist 1 . Fills 12 of 15 medications . Pharmacy computer system Portal to insurer No access to medical records or other pharmacy records .
Pharmacist 2 Fill 3 of 15 medications . Pharmacy computer system Portal to insurer No access to medical records or other pharmacy records . Laboratory . . LIS Draws and process blood test Report result to provider Patient portal Electronic papers send to specialist, paper reports faxed to PCP . . Family (husband daughter) caregiver and . . Go to medical appointments Call clinicians when symptoms get worst Make follow-up appointment. Get medical information from others Ensure all clinicians get medical information from others Stay with inpatient in hospital Coordinates with scheduling Calls in prescription refills Home medication list Home medical notebook File instructions from all providers List providers and phone numbers Files with administrative paperwork