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could perform a routine urine analysis. With my clinical expertise anyone with abdominal or back pain musy have their urine checked.After completing my physical assessment I complete my safety questions and history with the patient. During that time, I did a medication reconciliation with her home medications, reviewed her allergies and entered all information into EMR system Epic. When pulling up her history I was able to do a chart review and it allowed me to search and reviewed her old encounters in the system as well as her lab work. At this point, the tech has dipped her urine and it results some leuks in her urine. I concluded that she had past asymptomatic Urinary Tract Infection, which was only detected by urinalysis. I ordered a STAT Urinalysis laboratory workup with culture to be done the same day. Her EHR stated that she had no allergies to any medications. I placed an order for antibiotic bactrim 500mg 1 tablet every 12 hours for 3 days, to start right after her urinalysis test because it can alter the results if she takes it before the urine test. I told her I would get a notification immediately for the lab with her urine results. Utilizing the EMR I was able to view her past encounters, lab results and I was able to diagnose my patient appropriately because I was able to access her past visits and diagnostic testing through her EHR, which triggered past asymptomatic UTI. By looking over her EHR, it helped me order additional testing that pertained to her present health problem. It looks like Bactrim worked well for her in the past. I gave her strict return precautions and education prior to the end of her visit. Reference:
Mensah, N., Sukums, F., Awine, T., Meid, A., Williams, J., & Akweongo, P. et al. (2015). Impact of an electronic clinical decision support system on workflow in antenatal care: the QUALMAT eCDSS in rural health care facilities in Ghana and Tanzania.