Clinical Scenario
Enter a new patient into the system
Log on to the new patients CPRS record.
Enter a new allergy
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Enter an allergy to Ciprofloxacin (hint, because the patient has been newly entered into
the system and has no allergy assessment, you must enter the allergy from the ORDERS tab.)
Enter the patient’s provider as Doctor Eight, and the patient is being seen in Cardiology clinic.
Enter the allergy as historical, with symptoms of confusion, hives and rash. The reaction
occurred in June 2012 when the patient had a urinary tract infection.
Enter a set of vital signs for the patient.
BP: 145/90
Pulse: 92
Respirations: 26
Temperature: 101.2 (tympanic)
Weight: 186 lbs chair scale
Height: 72 inches (estimated)
Enter a new problem
Access the problems tab, select enter a new problem of Congestive Heart Failure that began
July 3, 2014. Add a comment that the congestive heart failure began after an acute MI in June
2014. The provider is DOCTOR EIGHT.
Orders
Access the orders tab in CPRS.
Select “add new orders”
The provider is “DOCTOR EIGHT” and the patient location is
CARDIOLOGY.
In the Add new orders screen, write orders for:
o TPR BP q 4 hours. Start date/ time should be NOW, and the Stop
date / time should be 7 days from now (hint: click on the “…” to
change the date / time to stop).
o Intake and Output for 7 days.
o Ambulate the patient TID for 3 days.
o Tylenol 650 mg by mouth every 8 hours. Enter a comment
indicating the Tylenol is for pain.
Verify that that the orders appear in BLUE as unsigned orders (Doctor
Eight will need to sign them before they appear as “active” orders).
Clinical Warning Note
 Enter a clinical warning note stating that the patient has a history
of MRSA and requires a private room for all admissions.
 Verify (on the cover sheet) that the note appears in the postings
section.
Select the progress note tab, and select “new note”. Enter the title
“Clinical Warning”
NOTE: Change date and time of note to
CURRENT DATE and time by clicking on
the box with … to open the calendar
Cover sheet listing the Clinical Warning note:
Enter a progress note summarizing a patient’s
condition during a shift.
 The patient is 2 days post bilateral knee replacement. His / her
wounds are without redness or drainage.
 Patient’s lung sounds have scattered rhonchi bilaterally and
required 3 nebulizer treatments resulting in clearing breath
sounds. No respiratory distress noted.
 The patient worked with PT to ambulate with no issues.
NOTE: Change date and time of note to
CURRENT DATE and time by clicking on
the box with … to open the calendar
Enter the text of the note, select sign note now. Review the
note in the progress note section.
Clinical Flowsheets
Enter data for your patient into the clinical flowsheets application.
Enter the following data into the identified sections of the
Training BC flow sheet
ADL section:
o
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Patient had a partial bath, up to chair and ambulated. Enter a comment that Physical
Therapy worked with the patient and instructed the patient how to safely ambulate.
The patient has normal bowel sounds and had 1 bowel movement.
Intake section
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At 10 am, the patient had 275 cc PO fluids and at 1 PM (1300) had another 325 cc of po
fluids.
At 10 am, 150 cc of IV med fluid and 11 am 250 cc of Blood products (add a comment
that the blood products were packed red blood cells)
Output section
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At 10 am, 250 cc urine output (add a comment that the patient has a urinary catheter)
and at 1 pm (1300) another 500 cc of urine output. (Note: you may need to change the
time according to the instructions provided in the screen shots below).
At 10 am, the patient vomited 100 cc emesis.
Pain Section
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The patient has a pain level of 5, with a goal of pain level of 1. The patient grimaces and
is restless. The pain is a dull constant pain relieved by medication and cold.
Integumentary Section
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The patient has bilateral knee incisions which are clean and dry. Enter a comment
stating that. Skin is otherwise intact.
Skin color is pink, temperature is warm, and is moist to touch with good turgor.
Upload the information from the flow sheet to a progress note in CPRS.
Prior to signing and uploading the note in the CP Flow Sheet
application, enter a note indicating that the patient was alert and
oriented to person and place for the entire shift.
After signing the note, verify that the note appears in CPRS, progress
notes section. The note title will appear as “general”.
Accessing Clinical Flowsheets:
Double click on the CP Flowsheets icon on the desktop. The log on
screen that appears is the same as CPRS – use your access and verify
codes.
Continue with each section until all data has been entered.
To upload as a progress note to CPRS:
Discharge Note
Enter a progress note that will provide a brief summary of the patient’s
hospitalization and the plan for the patients discharge.
Select the progress note title “General”.
At the beginning of the note, indicate that this is a discharge note.
Pertinent information about the hospitalization:
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Bilateral knee replacement
Stable post operative course, except developed a fever on post op day 4
due to a UTI. Treated with antibiotics.
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Ambulating with walker independently.
VNA will see pt daily at his / her home.
No skin breakdown
Bilateral incisions without redness or drainage
Current medications:
o Tylenol 650 mg po q8 hrs for pain
o Bactrim 1 tab BID for UTI
Patient has assistance in the home.
Shift Handoff Tool
Access the shift handoff tool. In the “task” section, enter a note that
the patient’s knee dressings should be changed BID at 8 am and 8 pm
with a DSD.
Log in using access and verify codes