Case Study: Exam and Patient Assessment –using EMR and ePrescribing

Patient Paul has a scheduled appointment with Ms. James, a Physician Assistant at Big City Family Practice, for a sore throat. Medical Assistant Allie escorts Patient Paul to the exam room, weighing him on the scale in the hall on the way. In the exam room, Medical Assistant Allie asks Mr. Smith the reason for his visit while taking his vital signs. Patient Paul states that he has had a sore throat for three days, that it has been getting worse and is really painful to swallow. Medical Assistant Allie documents Patient Paul’s chief complaint and vital signs and then confirms Patient Paul’s allergies and current medications before leaving the exam room.

Before entering the exam room, PA James looks over Patient Paul’s chart on the computer in the hallway. She notices that his chief complaint, sore throat, has triggered a local health alert for strep throat. PA James closes the record on the hall computer, enters the exam room and asks Patient Paul about his sore throat, how long ago it started, and if Patient Paul had run a fever. PA James also asks Patient Paul if he is taking any over the counter medications for his sore throat. Patient Paul states that he has been running a high fever, 101.5 degrees F, and that he is using aspirin for the fever and throat spray and cough drops, and gargles with salt water, and he adds that it has been several years since he has had a sore throat like this. PA James listens to Patient Paul’s heart and breathing then she examines his ears, nose, and throat. PA James asks if Patient Paul has had a runny nose, cough or hoarseness? Patient Paul states that he has not.

PA James tells Patient Paul that there are an unusually high number of strep cases in the community over the past month, and that based on the appearance of his throat that he may have strep throat, and that she would like to collect a sample by swabbing his throat with a q-tip and do a rapid strep test. Patient Paul agrees. PA James swabs his throat with a long cotton tipped swab, and does the test.

Five minutes later, PA James returns and tells Patient Paul that the test was positive and that she would like to start him on an antibiotic. Patient Paul readily agrees. PA James pulls his record up on the computer in the exam room, enters the rapid strep result, and asks Patient Paul if his Pharmacy is still the one on 555 Main St. Patient Paul answers affirmatively, and PA James sends the prescription electronically. PA James tells Patient Paul that the prescription will probably be ready on his way home, tells him to get some rest and to call the office if he does not feel better in three to five days or if his pain worsens.

Create an inventory of the processes explicitly stated or implied in this case study. For the implied processes, state a rationale for why you are certain this process exists. If in doubt about whether or not a process exists, mark it as “needs to be confirmed”.