Electronic Health Records

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  • Edition: 3rd
  • Format: Spiral Bound
  • Copyright: 2012-07-24
  • Publisher: McGraw-Hill Education

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Hamilton, Electronic Health Records, 3e is the top choice for training students using live and up-to-date SpringCharts EHR software. Electronic Health Records3e builds transferable medical documentation skills with a variety of exercises that walk students through different facets of using an EHR in the medical office. As students progress through SpringCharts, they learn to gather patient information, schedule appointments, record examination information, process lab tests, select codes, and more. Students who complete this course will learn the appropriate terminology and skills to use any EHR software program with minimal additional training. The practical, systematic approach is based on real-world medical office activities.

Table of Contents

Electronic Health Records, Third Edition

Chapter 1 The Electronic Health Record

1.1 Overview of the Electronic Health Record

The Concept

EHR Models

1.2 History of the Electronic Health Record

1.3 EHR Terminology

1.4 Government Involvement in the EHR

Medicare Improvements for Patients and Providers Act of 2008

American Recovery and Reinvestment Act of 2009

Beacon Community Program

Regional Extension Centers

1.5 Healthcare Processes and the EHR

1.6 Benefits of the EHR

Enhanced Accessibility to Clinical Information

Improved Patient Safety

Enhanced Quality of Patient Care

Greater Efficiency and Savings

1.7 Barriers to the EHR

Lack of Standards

Unknown Cost and Return on Investment

Concern about Difficulty Operating the System

Significant Changes in Clinic Processes

Lack of Trust and Safety

1.8 The Future of the Electronic Health Record

Chapter 2 Standards and Features of Electronic Health Records

2.1 History of EHR Standards

Health Insurance Portability and Accountability Act (HIPAA)

Consolidated Health Information (CHI)

Institute of Medicine (IOM)

The Certification Commission for Health Information Technology (CCHIT)

Office of the National Coordinator for Health Information Technology (ONC)

2.2 Meaningful Use (MU)

Computerized Physician Order Entry (CPOE)

2.3 Privacy and Security of the EHR

HIPAA and Privacy/Security

The Health Information Technology for Economic and Clinical Health (HITECH) Act

USA PATRIOT Act and Homeland Security

Other Privacy Concerns

2.4 EHR Implementation and Technology

2.5 Electronic Health Record Competencies

Chapter 3 Introduction and Setup

3.1 The Story of SpringCharts EHR and Its Features

Development of SpringCharts

Clinical Tools

Administrative Tools

Outside Links

Certification and Meaningful Use Criteria

3.2 User Preferences

Preferences 1

Preferences 2



New Address

EHR Exercise 3.1

3.3 Address Data Setup

New Address

Editing Addresses

EHR Exercise 3.2
EHR Exercise 3.3
EHR Exercise 3.4
EHR Exercise 3.5
EHR Exercise 3.6
EHR Exercise 3.7

3.4 Patient Data Setup

New Patient

Editing Patients

EHR Exercise 3.8
EHR Exercise 3.9
EHR Exercise 3.10

3.5 Insurance Data Setup

New Insurance Company

Editing Insurance Information

EHR Exercise 3.11
EHR Exercise 3.12

Chapter 4 The Clinic Administration

4.1 The Practice View Screen

EHR Exercise 4.1

4.2 The Appointment Calendar

EHR Exercise 4.2
EHR Exercise 4.3
EHR Exercise 4.4
EHR Exercise 4.5
EHR Exercise 4.6
EHR Exercise 4.7
EHR Exercise 4.8
EHR Exercise 4.9
EHR Exercise 4.10

4.3 The Patient Tracker

Color Coding

Location and Status

Tracker Group

Patient Info

Check Out

Tracker Archive

EHR Exercise 4.11
EHR Exercise 4.12
EHR Exercise 4.13
EHR Exercise 4.14
EHR Exercise 4.15
EHR Exercise 4.16
EHR Exercise 4.17

4.4 To-Do Lists and Reminders

My To Do List

EHR Exercise 4.18
EHR Exercise 4.19
EHR Exercise 4.20
EHR Exercise 4.21
EHR Exercise 4.22

4.5 Internal Messages

Nonpatient Messages

Messages Concerning Patients

EHR Exercise 4.23
EHR Exercise 4.24
EHR Exercise 4.25
EHR Exercise 4.26

4.6 Urgent Messages and E-Mails

EHR Exercise 4.27
EHR Exercise 4.28
EHR Exercise 4.29
EHR Exercise 4.30

Chapter 5 The Patient Chart

5.1 Overview of the Patient Chart

The Face Sheet

The Care Tree

EHR Exercise 5.1

5.2 Creating a Face Sheet


Social History

Past Medical History (PMHX)

Family Medical History (FMHX)


Chart Note

Routine Meds

Outside Meds

Problem List

Chart Alert

Patient Annotations

Patient Requests

Saving and Printing

EHR Exercise 5.2

5.3 Procedures in a Patient’s Chart

Adding the Primary Insurance

Entering Past Immunizations

Graphing Vital Signs

EHR Exercise 5.3
EHR Exercise 5.4

5.4 New Activities in a Patient’s Chart

New TC Note

New Vitals Only

New Letter to the Patient

New Letter About the Patient

New Test Report

New Excuse/Note/Order

EHR Exercise 5.5
EHR Exercise 5.6
EHR Exercise 5.7

Chapter 6 The Office Visit

6.1 Components of the Office Visit

6.2 Building an Office Visit Note

EHR Exercise 6.1
EHR Exercise 6.2
EHR Exercise 6.3

6.3 Activities within the Office Visit Screen

Editing the Patient’s Face Sheet

Modifying and Printing the Patient’s Immunization Record

Viewing and Graphing the Patient’s Lab Results

Creating an Excuse Note

Changing the Chart Tab

Report to Patient

EHR Exercise 6.4
EHR Exercise 6.5

6.4 Routing Slip

EHR Exercise 6.6

6.5 Adding Addendums to an Office Visit Note

EHR Exercise 6.7

6.6 Office Visit Reports

Report to Patient

Office Visit Note

History and Physical Report

Office Visit Template Reports

EHR Exercise 6.8
EHR Exercise 6.9
EHR Exercise 6.10

Chapter 7 Clinical Tools

7.1 Chart Evaluation

EHR Exercise 7.1

7.2 Test Orders

EHR Exercise 7.2

7.3 Evaluation & Management Coder

EHR Exercise 7.3

7.4 Superbill Form

EHR Exercise 7.4

7.5 Patient Instructions

EHR Exercise 7.5
EHR Exercise 7.6

7.6 Care Plans and Practice Guidelines

EHR Exercise 7.7

7.7 Drawing Program

7.8 Importing Documents

EHR Exercise 7.8

Chapter 8 Creating Templates

8.1 Creating Office Visit Templates

EHR Exercise 8.1
EHR Exercise 8.2

8.2 Creating Physician Order Templates

EHR Exercise 8.3

8.3 Creating Letter Templates

EHR Exercise 8.4

8.4 Template Manager

EHR Exercise 8.5

8.5 Creating Procedure Templates

EHR Exercise 8.6

Chapter 9 Tests, Procedures, and Codes

9.1 Ordering a Test

EHR Exercise 9.1
EHR Exercise 9.2

9.2 SpringLabs and Reference Lab Results

Access Stored Data

Manage Test Name Synonyms


Force Entering

EHR Exercise 9.3

9.3 Processing and Charting Tests

EHR Exercise 9.4
EHR Exercise 9.5

9.4 Creating a Test Report

EHR Exercise 9.6

9.5 Documenting, Activating, and Editing Procedure Codes

Documenting a Procedure

Creating a New Procedure

Creating an Immunization Procedure

Editing a Procedure

EHR Exercise 9.7

9.6 Documenting, Activating, and Editing Diagnosis Codes

Documenting a Diagnosis

Creating a New Diagnosis

EHR Exercise 9.8

Chapter 10 Productivity Center and Utilities

10.1 Bulletin Board

EHR Exercise 10.1

10.2 Integrated Faxing

Outbound Fax History

Inbound Fax List

Conversion Calculator

EHR Exercise 10.2

10.3 Time Clock

EHR Exercise 10.3

10.4 My Websites

EHR Exercise 10.4

10.5 Calculators

Conversion Calculator

Pregnancy EDD Calculator

Simple Calculator

EHR Exercise 10.5

10.6 Patient Database Reporting

Form Letters


EHR Exercise 10.6

10.7 Patient Archives

EHR Exercise 10.7

Chapter 11 Applying Your Knowledge

11.1 Practice View Screen

Office Schedule

EHR Exercise 11.1
EHR Exercise 11.2

Patient Tracker

EHR Exercise 11.3
EHR Exercise 11.4
EHR Exercise 11.5

To Do List

EHR Exercise 11.6
EHR Exercise 11.7


EHR Exercise 11.8
EHR Exercise 11.9
EHR Exercise 11.10

11.2 Patient Chart Screen

Face Sheet

EHR Exercise 11.11

Patient Chart Activities

EHR Exercise 11.12
EHR Exercise 11.13
EHR Exercise 11.14
EHR Exercise 11.15
EHR Exercise 11.16
EHR Exercise 11.17
EHR Exercise 11.18

11.3 Office Visit Screen

Office Visit Note

EHR Exercise 11.19
EHR Exercise 11.20

Office Visit Activities

EHR Exercise 11.21
EHR Exercise 11.22

Chapter 12 EHR Practicum

12.1 Recording Information from Paper Source Documents

EHR Exercise 12.1
EHR Exercise 12.2
EHR Exercise 12.3
EHR Exercise 12.4
EHR Exercise 12.5
EHR Exercise 12.6
EHR Exercise 12.7
EHR Exercise 12.8
EHR Exercise 12.9
EHR Exercise 12.10
EHR Exercise 12.11
EHR Exercise 12.12
EHR Exercise 12.13
EHR Exercise 12.14
EHR Exercise 12.15
EHR Exercise 12.16
EHR Exercise 12.17
EHR Exercise 12.18
EHR Exercise 12.19
EHR Exercise 12.20

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