Patient Chart Details Submission Form
Before you choose to write a patient chart, it is important to examine the potential educational merits
of the chart. Ask yourself the following questions:
What Learning Objectives could be met with use of this chart in a homework or skills
assignment?
Identify core knowledge, physical skills, or important decision-making experiences the student
can achieve through the use of this chart.
 What do you want the student to complete with this patient chart?
 What do you want the student to think about through this patient chart?
 What do you expect of the student in relationship to this patient chart?
How could the use of this chart enhance a simulation? What Learning Objectives could be met
with use of this chart in an interactive simulation setting?
 What data do you need to provide in the chart for base information about this patient?
 What skills or assessments should be done with this patient?
 What unexpected events or common clinical situations could be presented via the use
of this patient?
Charts can be simple or complex, long or short. All Neehr Perfect EHR patient charts contain some or all
of the following types of information. Please provide all patient chart data in the fields below.
Patient Chart Data:
OVERVIEW & EDUCATIONAL DATA
Patient chart summary/synopsis: (Freetext description of the patient scenario.)
Suggested uses: (List some ideas for curricular use of this chart. E.g. Particular skills practice, certain
type of medication administration, physical examination skills, pathophysiology, etc.)
DEMOGRAPHIC DATA
Demographics/Registration information:
Name:
Sex:
Date of Birth (only month and day are needed):
Age:
Medical Record Number:
Marital Status:
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Street Address:
City:
State:
Zip:
Home Phone:
Employment Status:
Parent or Guardian Information:
Guarantor Information:
Insurance:
Encounter (i.e. Visit or Admission) Data:
Inpatient or Outpatient:
Location- choose from:
 Central Clinic
 General Hospital
 Shoreline Birth Center
 Hillside Pediatric Hospital
 General Hospital ER
 Highlands Long Term Care
 Valley View Therapy Center
Description:
HEALTH DATA
Alerts Data (e.g. Allergies, Fall Risk, Isolation)
Type (choose from Advance Directive, Adverse Reaction/Allergy, Crisis Note, or Clinical Warning):
Status (choose from Active or Inactive):
Subject (May be Free text or marked as NKA):
Signs/Symptoms:
Notes and/or Attachments (Optional. Attachments can be in gif, jpg or png format only):
Problems Data (e.g. active, resolved, chronic or acute problems)
Date of onset:
Problem (name of problem with ICD code, if applicable):
Status (choose from Active, Inactive, Resolved, Removed):
Immediacy (choose from Acute, Chronic, Unknown, S/P):
Priority (freetext to be used if applicable, e.g. Presenting, Admitting, Primary, etc.):
Vitals Data (Include values and times. Repeat as many times as needed.)
Date/Time:
TPR B/P O2 (include qualifiers, if desired):
Pain (types include numerical, CRIES, Nonverbal and Wong Baker):
Growth & Development (weight, height/length, head circumference, if applicable):
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Intake & Output (include method and description, if desired):
Orders Tab: (Include all details below. Repeat as many times as needed.)
Date/Time:
Order Category (Available categories include Scheduled Med, Prescription, Laboratory, Diagnostics,
Consults, Procedures, Location, Supplies/Devices, Care, Screening/Measurements, Therapy):
Order Item: (This is the name of the medication, lab, diagnostic test, etc. being ordered):
Quantity (if applicable):
Route (if applicable):
Frequency:
Order Details (This is a longer text box that can contain freetext description or instructions for order
under when applicable):
Status (Most often the order status is “Active,” but an order can also be written as “On Hold,” “Flagged,”
“Pending,” “Expired,” “Completed,” or “Discontinued”):
Meds Tab:
Orders of the type “Scheduled Meds” will automatically show up on the Meds Tab. Active Scheduled
Meds are the only types of orders that can be administered using the barcoded eMAR.
Notes Tab: (Include all details below. Repeat as many times as needed.)
Hint: ** Most charts should contain a History & Physical or Admission Assessment and at least one
Progress Report to help tell the clinical story.
Note Title: (You may choose a title for your note. Common note titles examples are, “Progress Note,”
“H&P,” “XRay Report,” “Fall Risk Assessment,” “Teaching Plan,” etc.)
Date/Time:
Text of Note:
Images for note (if applicable):
Care Plans Tab: (Care Plans can be partial or complete. They help direct the student and focus their
patient care.)
Date/Time:
Care Plan Title/Nursing Diagnosis:
Related Medical Diagnosis:
Goal:
Interventions & Evaluations:
Outcomes:
Labs Tab:
Date/Time
Lab
ABGs
PaO2
PaCO2
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Results
Date/Time
Lab
ABGs
PaO2
PaCO2
Results
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pH
SaO2
HCO3
BMP
BUN
CO2
Creatinine
Glucose
Serum chloride
Serum potassium
Serum sodium
Complete Metabolic
Panel
Glucose, Serum
BUN
Creatinine, Serum
BUN/Creatinine Ratio
eGFR if NonAfrican
American
eGFR if African American
Sodium, Serum
Potassium, Serum
Chloride, Serum
Carbon Dioxide, Total
Calcium, Serum
Albumin, Serum
Protein, Total, Serum
A/G Ratio
Globulin, Total
Alkaline Phosphatase,
Serum
ALT (SGPT)
AST (SGOT)
Bilirubin, Total
CBC with Differential
Hemoglobin
Hematocrit
RBCs
RDW (RBC distribution
width)
MCV
MCH
MCHC
Platelet count
WBC
Segmented neutrophils
Band forms
Basophils
Archetype Innovations, LLC©2015
pH
SaO2
HCO3
BMP
BUN
CO2
Creatinine
Glucose
Serum chloride
Serum potassium
Serum sodium
Complete Metabolic
Panel
Glucose, Serum
BUN
Creatinine, Serum
BUN/Creatinine Ratio
eGFR if NonAfrican
American
eGFR if African American
Sodium, Serum
Potassium, Serum
Chloride, Serum
Carbon Dioxide, Total
Calcium, Serum
Albumin, Serum
Protein, Total, Serum
A/G Ratio
Globulin, Total
Alkaline Phosphatase,
Serum
ALT (SGPT)
AST (SGOT)
Bilirubin, Total
CBC with Differential
Hemoglobin
Hematocrit
RBCs
RDW (RBC distribution
width)
MCV
MCH
MCHC
Platelet count
WBC
Segmented neutrophils
Band forms
Basophils
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Eosinophils
Lymphocytes
Monocytes
CMP (Comprehensive
Metabolic Profile)
Albumin
Alkaline phosphatase
ALT (alanine
aminotransferase)
AST (aspartate
aminotransferase)
BUN (blood urea
nitrogen)
Calcium
Chloride
CO2 (carbon dioxide)
Creatinine
Glucose test
Potassium test
Sodium
Total bilirubin
Total protein
Creatine kinase (CK)
isoenzymes
CK-BB
CK-MB (cardiac)
Troponin
Creatine phosphokinase
(CPK)
Creatinine
Electrolytes
Calcium
Calcium, ionized
Chloride
Magnesium
Phosphate
Potassium
Sodium
Lipid Profile
Cholesterol, total
HDL cholesterol
LDL cholesterol
Triglycerides
Liver Panel (Liver
function panel)
ALT
AST
ALP
Archetype Innovations, LLC©2015
Eosinophils
Lymphocytes
Monocytes
CMP (Comprehensive
Metabolic Profile)
Albumin
Alkaline phosphatase
ALT (alanine
aminotransferase)
AST (aspartate
aminotransferase)
BUN (blood urea
nitrogen)
Calcium
Chloride
CO2 (carbon dioxide)
Creatinine
Glucose test
Potassium test
Sodium
Total bilirubin
Total protein
Creatine kinase (CK)
isoenzymes
CK-BB
CK-MB (cardiac)
CK-MM
Creatine phosphokinase
(CPK)
Creatinine
Electrolytes
Calcium
Calcium, ionized
Chloride
Magnesium
Phosphate
Potassium
Sodium
Lipid Profile
Cholesterol, total
HDL cholesterol
LDL cholesterol
Triglycerides
Liver Panel (Liver
function panel)
ALT
AST
ALP
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Albumin
Total protein
Bilirubin
GGT
LD
PT
Urinalysis
Color
Clarity/turbidity
pH
Specific gravity
Glucose
Ketones
Nitrates
Leukocyte esterase
Bilirubin
Urobilirubin
Blood
Protein
WBCs
Squamous epithelial
cells
Casts
Crystals
Bacteria
Yeast
Other Labs
Archetype Innovations, LLC©2015
Albumin
Total protein
Bilirubin
GGT
LD
PT
Urinalysis
Color
Clarity/turbidity
pH
Specific gravity
Glucose
Ketones
Nitrates
Leukocyte esterase
Bilirubin
Urobilirubin
Blood
Protein
WBCs
Squamous epithelial cells
Casts
Crystals
Bacteria
Yeast
Other Labs
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