Before to becoming a full-time author and consultant, Richard Gartee served as vice president of product development and subsequently as director of design strategy at Medical Manager Research & Development, Inc. His 20 years of experience in the design, development, and implementation of practice management and Electronic Health Records software dates back to the earliest days of the field. He was involved in the development of leading medical software systems including The Medical Manager, Intergy, and Intergy EHR, among others. Richard also served as a liaison to other companies in the medical computer industry as well as Blue Cross/Blue Shield plans, a U.S. Department of Commerce International Trade Mission, and various universities. He served as a voting member of two of the national standards groups currently guiding Electronic Health Record developments (ANSI X-12 and HL7 Standards groups discussed in Chapter 2). He has been a faculty member/speaker at (TEPR) the Electronic Health Records conference for over 10 years. He is the author of two previous textbooks on computerized medical systems.
Table of Contents | |
Preface | |
Introduction | |
Learning Made Easy | |
Organization of The Text | |
The Transfer of Acquired Skills to Actual EHR Systems | |
Software Requirements | |
A Few Words of Advice | |
About The Author | |
Acknowledgements | |
Electronic Health Records - An Overview What Are Electronic Health Records? | |
Why Electronic Health | |
Records Are Important | |
Health Maintenance | |
Trend Analysis | |
Alerts | |
Decision Support | |
Forces Driving The EHR | |
Wherersquo;s My Chart? - A Real Life Story | |
Health And Safety | |
National Coordinator for Health Information Technology | |
Readiness For Change | |
Vision for Consumer-centric and Information-rich Care | |
Strategic Framework | |
Building The EHR | |
Flow of Medical Information Into The Chart | |
Flow of an Office Fully Using EHR | |
Doctors Say | |
Transition To An EHR | |
Levels of EHR Implementation | |
Building The EHR In Steps | |
Comparing The EHR In An Inpatient Vs. Outpatient Setting | |
Methods of Capturing And Recording Data | |
Workflow of Physician Orders and Results | |
Lab Orders and Results | |
Comparison of Lab | |
Order And Results Workflow | |
Medication Orders | |
Radiology Orders and Reports | |
Electronic Data Interchange Between Systems and Devices | |
HL7 | |
CDISC | |
DICOM | |
Medical Devices | |
Summary | |
Coding Standards | |
The Value of Codified Electronic Health Records | |
Forms of EHR Data | |
Limitations of Types of Data | |
Comparison of Lab Results | |
Alerts | |
Health Maintenance | |
Standard Coding Systems | |
Government Influence On Coding Standards | |
Comparison of Prominent EHR Code Sets | |
How EHR Nomenclatures Differ From Other Code Sets | |
SNOMED CT | |
Medcin | |
LOINC | |
UMLS | |
Nursing Code | |
Sets | |
A Nurses Notes - A Real Life Story | |
How EHR Code Sets Differ From Billing Code Sets | |
CPT-4 | |
ABC | |
ICD-9CM | |
ICD-10 | |
NDC And Other Drug Codes | |
Conclusion | |
Summary | |
Learning Medical Record Software | |
Introducing The Medcin Student Edition | |
Understanding The Software | |
Hands On | |
Starting Up The Medcin Software | |
Navigating The Screen Hands On | |
Exiting And Re-Starting The software Hands On | |
Using The Menu to Select A Patient Hands On | |
Navigating The Medcin Findings Hands On | |
Tabs On The Medcin Nomenclature Panel | |
Data Entry Of The Examination Note Hands On | |
Creating An Encounter Hands On | |
Recording Subjective Findings Hands On | |
Removing Findings Hands On | |
Recording More Specific Findings Hands On | |
Recording History Findings | |
Adding Details To The Findings Hands On | |
Recording A Value | |
Using Free Text Hands On | |
Adding Free-text Hands On | |
Recording Objective Findings Hands On | |
Setting The Result Field Hands On | |
Adding Detail To Recorded Findings Hands On | |
Adding Episode Detail To Findings Hands On | |
Recording The Assessment Hands On | |
Recording Treatment Plan And Physician Orders | |
Introduction To Using Forms Hands On | |
Recording The Chief Comp | |
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