EMR, Vital Signs, and Lab Values- oh my!

Electronic medical record (EMR)

electronic record of an individual’s health-related information that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization

Electronic health record (EHR)

inter-organizational system, aggregate all of the data being generated by individual EMRs

Personal health record (PHR)

systems used by patients

Benefits of EMRs

• decreased overall healthcare costs

• reduction in errors

• reduction of waste

• ability to share results of lab and other important info

• improved access to timely and accurate info

• reduced uncertainty in clinical decision making

• improved adherence to appointments

• improved compliance with regulatory bodies and reimbursement claims processing

info in EMR

• patient demographics

• billing info

• disease states

• med orders

• medication admin records

• allergies

• immunizations

• vital signs

• lab values

• imaging

• ins and outs

• progress notes

• chart reviews

traditional vital signs

• temp

• HR

• RR

  • BP

normal oral temperature range

95\.9-99.5 F (35.5-37.5 C)

oral temp fever

>99.5F (>37.5 F)

Heart rate

number of times the heart beats per minute

\

normal HR

60-100 bpm

bradycardia

tachycardia

>100 bpm

Respiratory rate

number of breaths per minute

normal RR

12-20 bpm

Tachypnea

>20 bpm; rapid breathing

Bradypnea

apnea

absence of breathing

dyspnea

SOB

orthopnea

difficulty breathing in supine position (laying on back)

hyperventilation

increased rate and depth of breathing

hypoventilation

decreased rate and depth of breathing

normal BP

systolic

goal BP for patients with HTN

hypotension

low blood pressure

how many blood pressure readings are needed to diagnose a patient with HTN?

at LEAST 2

orthostasis

low BP that occurs when standing up

High prefix/suffix

hyper- -cytosis

Low prefix/suffix

Hypo- -penia

What does one lab value signify

the patient’s levels at one specific point in time

Basic metabolic panel (BMP)

measure of electrolytes, acid-base balance, kidney function, and blood sugar

Na normal range

135-145

K normal range

3\.5-5

Cl normal range

95-105

Bicarb normal range

22-28

BUN normal range

10-20

Serum Creatinine (SCr) normal range

.6-1.2

glucose normal range

70-99

What do you fix first if both Mg and K levels are low?

Mg

What is a good way for pts to replenish K?

Eat foods with KCl salt rather than NaCl

Causes of hyperkalemia

• increased K intake

• decreased K excretion (renal failure)

• extracellular K shifts (acidosis/cell damage)

• ACE inhibitors

• ARBs

• K-sparing diuretics

  • NSAIDs

hyperkalemia treatment

• stop supplements

• stabilize cardiac membrane with CA

• decrease EC K through IC shift

• enhance removal from the body