Electronic Health Records Understanding and Using Computerized Medical Records(2-downloads)

by Gartee, Richard

• ISBN13: 9780134345383
• ISBN10: 013434538X
• Edition: 3rd
• Copyright: 2016-10-12
• Publisher: Pearson

Summary

This is the eBook of the printed book and may not include any media, website access codes, or print supplements that may come packaged with the bound book.

 

For use in courses that cover EHRs in Medical Assisting, undergraduate RN and LVN nursing programs, and as a supplement to other allied professional curriculums (including RT, PT, and OT). Also useful for continuing education courses covering EHR.

A complete,”learn by doing” approach to learning electronic health records

Designed to prepare an educated clinical workforce, Electronic Health Records: Understanding and Using Computerized Medical Records is the complete “learn by doing” text and software package for everyone who must use an electronic health records (EHR) system, including doctors, nurses, medical assistants, physician assistants, and other medical office staff. It provides a thorough understanding of EHR tasks and functional benefits that is continuously reinforced by actual EHR experiences. Updated to reflect the latest EHR rules, regulations, and innovations, this new edition contains even more hands-on exercises that use real EHR software to transform theoretical EHR concepts into practical understanding.

Author Biography

Richard Gartee is the author of seven college textbooks on health information technology, computerized medical systems, managed care, and electronic health records. He is also the author of the novel, Lancelot’s Grail. Before becoming a full-time author and consultant, Richard spent 20 years in the design, development, and implementation of the preeminent practice management and electronic health records systems.

Richard also served as a liaison to other companies in the medical computer industry as well as Blue Cross/Blue Shield, a U.S. Department of Commerce International Trade Mission, various universities, and EHR design consultant for the Aravind Eye Care System hospitals.

Richard is a current or past member of many of the professional organizations and national standards groups recommended in this book:

• American Health Information Management Association (AHIMA)
• Healthcare Information Management Systems Society (HIMSS)
• American National Standards Institute (ANSI) X12n Committee for Development of Electronic Claims Standards
• Health Level Seven (HL7) Committee for Development of Claims Attachment Standards
• Workgroup for Electronic Data Interchange (WEDI) Task Force for Development of Electronic Remittance Guidelines
• A faculty member/speaker at the Medical Records Institute international Electronic Health Records Conference (TEPR) for 12 years
  

Table of Contents

Chapter 1. History and Evolution of Electronic Health Records

History of Electronic Health Records

Institute of Medicine (IOM)

Computer-based Patient Record Institute (CPRI)

Health Insurance Portability and Accountability Act (HIPAA)

EHR Defined

Social Forces Driving EHR Adoption

Health Safety

Health Costs

Changing Society

Group Discussion Topic: EHR News

Forces Driving EHR Evolution

Office of National Coordinator for Health Information Technology

Strategic Framework

Federal Health IT Strategic Plan

The HITECH Act

Strategic Plan Updates

Meaningful Use of a Certified EHR

Certified EHR

Meaningful Use and Clinical Quality Measures

EHR Adoption After HITECH

Why Interoperability Is Important

Group Discussion Topic: When the Chart Is Lacking

Documenting at the Point of Care

Real-Life Story: Where’s My Chart?

Flow of Clinical Information into the Chart

Workflow of an Office Using Paper Charts

Workflow of an Office Fully Using an EHR

Group Discussion About Workflow

Inpatient Charts versus Outpatient Charts

Patient Registration and Appointment Scheduling

Patient Administration

Tutorial Exercise 1A: Overview of a Patient Administration Module

Patient and Provider Scheduling

Tutorial Exercise 1B: Overview of a Scheduling Module

Chapter One Summary

Chapter 2. Functional EHR Systems

Format of Data Determines Potential Benefits

EHR Data Formats

Limitations of Certain Types of Data

Standard EHR Coding Systems

Prominent EHR Code Sets

SNOMED-CT

SNOMED-CT Structure

Medcin

Medcin Structure

LOINC

Clinical Care Classification System (CCC)

RxNorm

UMLS

How EHR Code Sets Differ From Code Sets Used for Billing

ICD-10CM  

CPT-4®

Code Usage

Exchanging Data with Other Standard Code Sets

Capturing and Recording EHR Data

Importing Digital Images

Guided Exercise 2A: Exploring a Document Imaging System

Cataloging Digital Images

Guided Exercise 2B: Importing and Cataloging Images

Picture Archival and Communication System (PAC)

Importing Text to the EHR

Importing Coded EHR Data

Patient-Entered Data

Provider-Entered Data

Health Information Exchange

HL7

DICOM

CDISC

Biomedical Devices

Telemonitors

Real-Life Story: Enhancing Process Efficiency through Remote Access

Functional Benefits from Codified Records

Trend Analysis

Critical Thinking Exercise 2C: Retrieving a Scanned Lab Report

Lab Report as Digital Image

Lab Report as Text Data

Coded Lab Data

Alerts

Drug Utilization Review

Formulary Alerts

Other Types of Alerts

Health Maintenance

Preventive Care

Immunizations

Decision Support

Meeting the IOM Definition of an EHR

Chapter Two Summary

Chapter 3. Learning Medical Record Software

Introducing the Quippe® Student Edition Software

About the Exercises in This Book

Creating Your First Patient Encounter Note

Guided Exercise 3A: Understanding the Software

Understanding the Toolbar

Navigating Medcin Content

Guided Exercise 3B: Adding Clinical Concepts to the Workspace

Using a More Specific Finding

Guided Exercise 3C: Patient with Caffeine Withdrawal Headache

Adding Details to the Findings

Guided Exercise 3D: Using the Details Pop-up Window

Chief Complaint and Vital Signs

Guided Exercise 3E: Recording Chief Complaint and Vital Signs

Critical Thinking Exercise 3F: A Patient Suffering Withdrawal Headaches

Real-Life Story: Paperless in Less Than a Day

Chapter Three Summary

Testing Your Skill Exercise 3G: Another Cause of Headache

Chapter 4. Increased Familiarity with EHR Software

Applying Your Knowledge

Documenting a Brief Patient Visit

Guided Exercise 4A: Documenting a Visit for Common Cold

Visually Different EHR Styles

Real-Life Story: A Nurse’s Notes

Guided Exercise 4B: Recording Findings Using Alternate Methods

Encounter Notes Without Yes/No Check Boxes

Additional Exercises

Critical Thinking Exercise 4C: A Patient with Sinusitis

Critical Thinking Exercise 4D: Patient with Urinary Problem

Chapter Four Summary

Testing Your Skill Exercise 4E: An Asthma Patient Who Sleeps with a Dog

Chapter 5. Data Entry at the Point of Care

Why Speed of Entry Is Important in the EHR

Templates, Lists, and Forms Speed Data Entry

Shortcuts That Speed Documentation of Typical Cases

The Concept of Templates

The Concept of Lists

Guided Exercise 5A: Using an Adult URI List

Review of Systems and Pertinent Negatives

Guided Exercise 5B: Using Lists and Otherwise Normal

Critical Thinking Exercise 5C: Using Syncope List for a TIA Case

The Concept of Forms

Comparison of Lists and Forms

Initial Intake Form for an Adult

Guided Exercise 5D: Using Forms

Customized Forms

Real-Life Story: How I Learned to Stop Worrying and Love Forms

Critical Thinking Exercise 5E: Using a Form and a List

Chapter Five Summary

Testing Your Skill Exercise 5F: A Patient with Dyspnea

Chapter 6. Understanding Electronic Orders

The Importance of Electronic Orders and Results

Recording Orders in the Student Edition

Learning to Use the Search and Prompt Features

How Search Works

Guided Exercise 6A: Using Search and Prompt, and Ordering Tests

Moving Concepts and Findings to a Different Section

Merge Prompt—Intelligent Prompting

Lab Orders and Reports

Workflow of Electronic Lab Orders and Results

Guided Exercise 6B: Ordering an X-Ray

Radiology Orders and Reports

Workflow of Radiology Orders

Critical Thinking Exercise 6C: Ordering Tests and an X-Ray

Protocols Based on Diagnosis

Primary and Secondary Diagnoses

Multiple Diagnoses

The Rule-Out Diagnosis

Using Symptoms and History to Prompt for Findings

Guided Exercise 6D: Patient With Multiple Diagnoses

Medication Orders

Electronic Prescriptions

Closing the Loop on Safe Medication Administration

Guided Exercise 6E: Writing Prescriptions in an EHR

Quick Access to Frequent Orders

Guided Exercise 6F: Ordering Medications Using Discharge Orders

Real-Life Story: When Orders and Results Are Critical

Chapter Six Summary

Testing Your Skill Exercise 6G: Discharging a Patient with Deep Vein Thrombosis

Comprehensive Evaluation of Chapters 1–6

Part I–Testing Your Knowledge of Chapters 1–6

Part II–Guided Exercise CE1: Document Image Retrieval

Part III–Critical Thinking Exercise CE2: ER Visit for Shortness of Breath

Chapter 7. Problem Lists, Lab Results, and Body Mass Index

Longitudinal Patient Records to Manage Patients’ Health

Understanding Problem Lists

The Problem-oriented Chart

Guided Exercise 7A: Working With a Problem-oriented Chart

Citing Previous Encounter Data

Guided Exercise 7B: Adding Problems, Retrieving and Citing Lab Results

Orders and Results Management

Guided Exercise 7C: Retrieving Pending Lab Results

Critical Thinking Exercise 7D: Using Lab Results to Rule Out Lead Poisoning

Body Mass Index

Real-Life Story: Experiencing the Functional Benefits of an EHR

Waist Circumference and BMI

Critical Thinking Exercise 7E: Determining BMI Category for a Patient

Guided Exercise 7F: Calculating BMI and Trending Weight for a Diabetic Patient

Critical Thinking Exercise 7G: Discovering Your BMI and Category

Chapter Seven Summary

Testing Your Skill Exercise 7H: Patient with Upper Abdominal Chest Pain

Chapter 8. Flow Sheets, Annotated Drawings, and Graphs

Learning to Use Flow Sheets

Guided Exercise 8A: Working with a Flow Sheet

About the Flow Sheet View

Guided Exercise 8B: Obstetric Patient’s Flow Sheet

Critical Thinking Exercise 8C: Flow Sheet with Multiple Diagnoses

Use of Anatomical Drawings in the EHR

Navigation by Body System

Annotated Drawings as EHR Data

Guided Exercise 8D: Annotated Dermatology Exam

Critical Thinking Exercise 8E: Examination of a Patient with Pressure Sores

Real-Life Story: First Patient Whose Life Was Saved by Expert System Software He Operated Himself

Using Graphs to View Trends

Visual Aids to Engage Patients in Their Own Healthcare

Guided Exercise 8F: Trending with a Graph and Flow Sheet

Critical Thinking Exercise 8G: Graphing Weight and BMI

Chapter Eight Summary

Testing Your Skill Exercise 8H: Diabetic with High Blood Pressure

Chapter 9. Using the EHR to Improve Patient Health

Prevention and Early Detection

Pediatric Wellness Visits

Guided Exercise 9A: Well-Baby Checkup

Understanding Growth Charts

What Is a Percentile?

CDC Growth Charts

Guided Exercise 9B: Pediatric Vitals and Growth Charts

The Importance of Childhood Immunizations

Guided Exercise 9C: Reviewing and Ordering Vaccines

Critical Thinking Exercise 9D: Determine Your Adult Immunizations

Preventative Care Screening

Clinical Quality Measures

Real-Life Story: Quality Care for Pediatric and Adult Patients

Guided Exercise 9E: Applying Quality Measures to Patient Care

About the Quality Measures Review

Critical Thinking Exercise 9F: Clinical Quality Measures for a Female Patient

The Patient-Centered Medical Home

Chapter Nine Summary

Testing Your Skill Exercise 9G: Baby’s First Checkup

Chapter 10. Decision Support and Patient Involvement

Enriching the EHR Through Connectivity

Decision Support

Integrated Decision Support

Guided Exercise 10A: Patient with Dengue Fever

Critical Thinking Exercise 10B: Accidental Exposure to Paraquat

Patient Involvement in Their Own Healthcare

Patient Education Material

Guided Exercise 10C: Patient Education About Risk of COPD

Critical Thinking Exercise 10D: Patient Education About Diabetes

Using the Internet

Critical Thinking Exercise 10E: Internet Medical Research

Secure Internet Data

Remote EHR Access for the Provider

Practicing Medicine Online

Asynchronous Telemedicine at Mayo Clinic

Teleradiology

Telemedicine in Nursing

Telemedicine via E-Visits

Patient Entry of Symptoms and History

Workflow Using Patient-Entered Data

Internet Workflow

Improved Patient Information

Guided Exercise 10F: Experiencing Patient-Entered HPI

Guided Exercise 10G: Reviewing Patient-Entered Data

E-Visits

Real-Life Story: Using the Internet to Build a Patient-Centered Practice

Mayo Clinic Study of E-visits

E-Visits in Practice

Workflow of an E-Visit

Guided Exercise 10H: Patient Requests an E-Visit

Critical Thinking Exercise 10J: Clinician Completes the E-Visit

Patient Access to Electronic Health Records

Chapter Ten Summary

Testing Your Skills Exercise 10K: A Patient with Hepatitis A

Chapter 11. Privacy and Security of Health Records

Understanding HIPAA

Administrative Simplification Subsection

HIPAA Transactions and Code Sets

HIPAA Transactions

Standard Code Sets

HIPAA Uniform Identifiers

HIPAA Privacy Rule

Privacy Policy

Consent

Modifying HIPAA Consent

Critical Thinking Exercise 11A: Creating a Privacy Policy

Authorization

Research

Research Exceptions

Marketing

Guided Exercise 11B: Authorization for Release of PHI

Government Agencies

Minimum Necessary

Incidental Disclosures

A Patient’s Right to Know About Disclosures

Patient Access to Medical Records

Personal Representatives

Minor Children

Critical Thinking Exercise 11C: What Is Required?

Business Associates

Electronic Health Information Exchange

Real-Life Story: The First Hipaa Privacy Case

Civil and Criminal Penalties

HIPAA Security Rule

Why a Security Rule?

The Privacy Rule and Security Rule Compared

Critical Thinking Exercise 11D: Comparing Privacy and Security Rules

Security Standards

Implementation Specifications

Administrative Safeguards

Security Management Process

Critical Thinking Exercise 11E: How to Assess Security Risk

Assigned Security Responsibility

Workforce Security

Information Access Management

Security Awareness and Training

Security Incident Procedures

Contingency Plan

Evaluation

Critical Thinking Exercise 11F: Developing a Contingency Plan

Real-Life Story: Contingency Plans Ensure Continued Ability to Deliver Care

Business Associate Contracts and Other Arrangements

Physical Safeguards

Facility Access Controls

Workstation Use

Workstation Security

Device and Media Controls

Technical Safeguards

Access Control

Audit Controls

Integrity

Person or Entity Authentication

Transmission Security

Organizational, Policies and Procedures, and Documentation Requirements

Organizational Requirements

Policies and Procedures

Documentation

Minimizing the Risk of Mobile Devices

Critical Thinking Exercise 11G: Securing EHR Access

Breach Notification Requirements

Individual Notice

Media Notice

Notice to the Secretary

Notification by a Business Associate

Electronic Signatures for Health Records

HIPAA Privacy, Security, and You

Chapter Eleven Summary

Chapter 12. EHR Coding and Reimbursement

The EHR and Reimbursement

HIPAA-Required Code Sets

Diagnoses Codes Justify Billing

Primary and Secondary Diagnoses

Multiple Diagnoses

Guided Exercise 12A: Using Code Review

CPT-4 and HCPCS Codes

Evaluation and Management (E&M) Codes

Four Levels of E&M Codes

How the Level of an E&M Code Is Determined

Undercoding

Accurate Coding

Using EHR Software to Understand E&M Codes

Guided Exercise 12B: Calculating the E&M Code from an Encounter

Key Components

Levels of Key Components

Key Component: History

Key Component: Examination

Guided Exercise 12C: Understanding the Examination Component

Levels of Key Component: Examination

Key Component: Medical Decision Making

Guided Exercise 12D: Understanding the MDM Component

Determining the Level of Medical Decision Making

Other Components: Counseling, Coordination of Care, and Time

Putting It All Together

Evaluating Key Components

How Changes in Key Components Affect the E&M Code

Guided Exercise 12E: Calculating E&M for a More Complex Visit

Guided Exercise 12F: Counseling Over 50 Percent of Face-to-Face Time

Critical Thinking Exercise 12G: Understanding How Procedures Are Posted to the Billing System

Real-Life Story: A New Level of Efficiency in Addition to Improved E&M Coding

Factors That Affect the E&M Code Set

Guided Exercise 12H: Exploring Other Factors of E&M Codes

Clinical Setting

Detailed Service Type

Exam Type

Chapter Twelve Summary

Testing Your Skill Exercise 12J: Counseling an Established Patient

Comprehensive Evaluation of Chapters 7–12

Part I—Testing Your Knowledge of Chapters 7–12

Part II—Critical Thinking Exercise CE3: Examination of a Patient with Arterial Disease

Part III—Critical Thinking Exercise CE4: Counseling and Education for a Patient with Arterial Disease

Part IV—Testing Your Skill Exercise CE5: Patient Signs HIPAA Authorization

Glossary

Index

Acronyms