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 Ampicillin (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 the Emergency
Department.
Enter the allergy as historical, with symptoms of itching, hives and rash. The reaction occurred
in January 2011 when the patient had a strep throat infection.
Enter a set of vital signs for the patient.
BP: 105/60
Pulse: 53
Respirations: 26
Temperature: 100 (tympanic)
Weight: 172 lbs bed scale
Height: 63 inches (estimated)
Enter a new problem
Access the problems tab, select enter a new problem of Chronic Obstructive Pulmonary Disease
that began in 2012. Add a comment that the patient is a lifelong 2 PPD smoker. 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 Emergency
Department.
In the Add new orders screen, write orders for:
o Diagnosis COPD exacerbation
o TPR BP q 2 hours. Start date/ time should be NOW, and the Stop
date / time should be 5 days from now (hint: click on the “…” to
change the date / time to stop).
o Intake and Output for 2days.
o Place patient on telemetry (cardiac monitoring)
o Portable EKG (enter using free text option)
o Albuterol Inhaler 2 puffs q 6 hours.
Verify that that the orders appear in BLUE as unsigned orders (Doctor
Eight will need to sign them before they appear as “active” orders).
Verify that the unsigned orders appear (in bold blue) on the orders tab.
Clinical Warning Note
 Enter a clinical warning note stating that the patient has a history
of falls and needs to be placed on fall precautions.
 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
On the menu bar, select “action” SIGN NOTE NOW
Cover sheet listing the Clinical Warning note:
Enter a progress note summarizing a patient’s
condition during a shift.
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The patient was admitted with a COPD exacerbation and possible pneumonia.
The patient has frequent episodes of shortness of breath, especially on exertion and requires
oxygen at 3 LPM via nasal cannula.
The patient has functional limitations and is starting to work with PT and OT, and may require
rehab.
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Pt has an IV in his/ her left hand with good blood return
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:
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Patient had a complete, turned and positioned and was up in the chair. Enter a
comment that the patient required the assistance of 2 staff and was unsteady when
transferring from bed to chair.
The patient has hypoactive bowel sounds and has not a bowel movement. Enter a
comment that the patient complains of intermittent abdominal pain.
Intake section
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At 8 am, the patient had 325 cc PO fluids and at 1 PM (1300) had another 500 cc of po
fluids.
At 8 am, 150 cc of IV med fluid and 11 am 500 cc IV fluid (add a comment that a 500 cc
IV fluid bolus was given for low blood pressure)
Output section
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At 10 am, 250 cc urine output (add a comment that the patient was incontinent as well
as voiding) and at 2 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 200+ cc emesis.
Pain Section
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The patient has a pain level of 8, with a goal of pain level of 1. The patient cries and
moans. The pain is a sharp, constant pain in their left lower leg. The pain relieved by
medication and cold.
Integumentary Section
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The patient’s skin has breakdown. Add a comment indicating that there is a small area
of breakdown 3cm x 2 cm on the left heal.
Skin color is pink, temperature is warm, slightly diaphoretic. Good skin turgor.
Pressure Ulcer
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Left heal has a partial thickness breakdown, 3 cm x 2 cm, heal boot on patient, Covered
with DSD. Add a comment that the wound care nurse was contracted to see the
patient.
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 stating that the patient was intermittently
confused during the shift and fell attempting to get out of bed.
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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COPD exacerbation, community acquired pneumonia.
Patient requires additional PT and OT and will be discharged to a local
rehab facility for continued strengthening.
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Intermittently confused, responds to reminder cues about safety
Skin breakdown on left heal improving – now 1 X 2 cm.
Current medications:
o Albuterol inhaler 2 puffs q 6 hrs
Patient has no support system at home.
Shift Handoff Tool
Access the shift handoff tool. In the “task” section, enter a note that
the patient requires the assistance of 2 staff and gait belt to transfer
from bed to chair. Make an additional entry that patient is at risk for
falls and additional skin breakdown.
Log in using access and verify codes.