Electronic Health Records Understanding and Using Computerized Medical Records

by Gartee, Richard

• ISBN13: 9780131960794
• ISBN10: 0131960792
• Edition: 1st
• Format: Paperback
• Copyright: 2006-04-07
• Publisher: Pearson

Summary

Electronic Health Records, a foundational course in Health Information Management or Health Information Technology programs is the next "big thing" in medical technology. It coordinates exam notes, the diagnosis, the insurance billing and coding, and any procedures for each patient's medical records. Gartee's, first of its kind, "how to" text is designed to train future users of EHR programs. It is written for the clerk, the Medical Records Technician, the general administrative Medical Assistant, the Medical Biller, the Insurance Coordinator and others in the operational level. It contains screen shots, exercises and activities to help students learn how an Electronic Health Records system works and how it serves as a "coordinator" of the different facets of patient medical administration. Gartee differs from all other publications, in that they discuss EHR's as they relate only to managers, planners, and top administrators in Hospitals.

Author Biography

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

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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