Electronic Health Records Understanding and Using Computerized Medical Records

  • ISBN13:


  • ISBN10:


  • Edition: 3rd
  • Format: Paperback
  • Copyright: 2016-06-07
  • Publisher: Pearson

Note: Supplemental materials are not guaranteed with Rental or Used book purchases.

Purchase Benefits

  • Free Shipping On Orders Over $35!
    Your order must be $35 or more to qualify for free economy shipping. Bulk sales, PO's, Marketplace items, eBooks and apparel do not qualify for this offer.
  • Get Rewarded for Ordering Your Textbooks! Enroll Now
List Price: $113.32 Save up to $107.67
  • Rent Book $11.54
    Add to Cart Free Shipping

    *This item is part of an exclusive publisher rental program and requires an additional convenience fee. This fee will be reflected in the shopping cart.

Supplemental Materials

What is included with this 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.

Also available with MyLab™ Health Professions

MyLab HealthProfessions for Gartee’s Electronic Health Records is an online homework, tutorial, and assessment program designed to work with this text to engage students and improve results. The MyLab Health Professions course includes 50% more hands-on, guided and critical-thinking exercises utilizing real EHR software. This new EHR software is cloud-based (no software download required), PC/Mac compatible, and accessible anytime, anywhere. Best of all, activities are auto-graded to save you time and help students progress through their course.

Note: You are purchasing a standalone product; MyLab Health Professions does not come packaged with this content. Students, if interested in purchasing this title with MyLab Health Professions, ask your instructor for the correct package ISBN and Course ID. Instructors, contact your Pearson representative for more information.

If you would like to purchase both the physical text and MyLab Health Professions, search for:

0134458788 / 9780134458786 Electronic Health Records: Understanding and Using Computerized Medical Records Plus NEW MyLab Health Professions with Pearson eText-- Access Card Package, Third Edition, package consists of:

  • 0134257502 / 9780134257501 Electronic Health Records: Understanding and Using Computerized Medical Records

  • 0134294254 / 9780134294254 MyLab Health Professions with Pearson eText --Access Card--for Electronic Health Records: Understanding and Using Computerized Medical Records


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 1
History of Electronic Health Records 1
Institute of Medicine (IOM) 2
Computer-based Patient Record Institute (CPRI) 4
Health Insurance Portability and Accountability Act (HIPAA) 4
EHR Defined 4
Social Forces Driving EHR Adoption 5
Health Safety 5
Health Costs 6
Changing Society 6
Group Discussion Topic: EHR News 7
Forces Driving EHR Evolution 7
Office of National Coordinator for Health Information Technology 7
Strategic Framework 7
Federal Health IT Strategic Plan 8
The HITECH Act 8
Strategic Plan Updates 8
Meaningful Use of a Certified EHR 10
Certified EHR 10
Meaningful Use and Clinical Quality Measures 10
EHR Adoption After HITECH 12
Why Interoperability Is Important 13
Group Discussion Topic: When the Chart Is Lacking 14
Documenting at the Point of Care 14
Real-Life Story: Where’s My Chart? 15
Flow of Clinical Information into the Chart 18
Workflow of an Office Using Paper Charts 18
Workflow of an Office Fully Using an EHR 20
Group Discussion About Workflow 23
Inpatient Charts versus Outpatient Charts 23
Patient Registration and Appointment Scheduling 26
Patient Administration 26
Tutorial Exercise 1A: Overview of a Patient Administration Module 27
Patient and Provider Scheduling 28
Tutorial Exercise 1B: Overview of a Scheduling Module 30
Chapter One Summary 31

Chapter 2. Functional EHR Systems 34
Format of Data Determines Potential Benefits 34
EHR Data Formats 35
Limitations of Certain Types of Data 36
Standard EHR Coding Systems 36
Prominent EHR Code Sets 37
SNOMED-CT Structure 38
Medcin 38
Medcin Structure 39
Clinical Care Classification System (CCC) 41
RxNorm 41
How EHR Code Sets Differ From Code Sets Used for Billing 42
ICD-10CM  42
CPT-4® 42
Code Usage 43
Exchanging Data with Other Standard Code Sets 43
Capturing and Recording EHR Data 44
Importing Digital Images 44
Guided Exercise 2A: Exploring a Document Imaging System 44
Cataloging Digital Images 49
Guided Exercise 2B: Importing and Cataloging Images 51
Picture Archival and Communication System (PAC) 56
Importing Text to the EHR 56
Importing Coded EHR Data 57
Patient-Entered Data 57
Provider-Entered Data 57
Health Information Exchange 58
HL7 58
Biomedical Devices 59
Telemonitors 59
Real-Life Story: Enhancing Process Efficiency through Remote Access 60
Functional Benefits from Codified Records 60
Trend Analysis 60
Critical Thinking Exercise 2C: Retrieving a Scanned Lab Report 61
Lab Report as Digital Image 61
Lab Report as Text Data 62
Coded Lab Data 62
Alerts 63
Drug Utilization Review 64
Formulary Alerts 65
Other Types of Alerts 66
Health Maintenance 66
Preventive Care 68
Immunizations 68
Decision Support 69
Meeting the IOM Definition of an EHR 69
Chapter Two Summary 70

Chapter 3. Learning Medical Record Software 72
Introducing the Quippe® Student Edition Software 72
About the Exercises in This Book 73
Creating Your First Patient Encounter Note 73
Guided Exercise 3A: Understanding the Software 74
Understanding the Toolbar 81
Navigating Medcin Content 82
Guided Exercise 3B: Adding Clinical Concepts to the Workspace 83
Using a More Specific Finding 91
Guided Exercise 3C: Patient with Caffeine Withdrawal Headache 91
Adding Details to the Findings 96
Guided Exercise 3D: Using the Details Pop-up Window 97
Chief Complaint and Vital Signs 101
Guided Exercise 3E: Recording Chief Complaint and Vital Signs 102
Critical Thinking Exercise 3F: A Patient Suffering Withdrawal Headaches 105
Real-Life Story: Paperless in Less Than a Day 112
Chapter Three Summary 113
Testing Your Skill Exercise 3G: Another Cause of Headache 117

Chapter 4. Increased Familiarity with EHR Software 119
Applying Your Knowledge 119
Documenting a Brief Patient Visit 120
Guided Exercise 4A: Documenting a Visit for Common Cold 120
Visually Different EHR Styles 125
Real-Life Story: A Nurse’s Notes 126
Guided Exercise 4B: Recording Findings Using Alternate Methods 128
Encounter Notes Without Yes/No Check Boxes 136
Additional Exercises 136
Critical Thinking Exercise 4C: A Patient with Sinusitis 137
Critical Thinking Exercise 4D: Patient with Urinary Problem 142
Chapter Four Summary 146
Testing Your Skill Exercise 4E: An Asthma Patient Who Sleeps with a Dog 147

Chapter 5. Data Entry at the Point of Care 150
Why Speed of Entry Is Important in the EHR 150
Templates, Lists, and Forms Speed Data Entry 151
Shortcuts That Speed Documentation of Typical Cases 151
The Concept of Templates 152
The Concept of Lists 152
Guided Exercise 5A: Using an Adult URI List 153
Review of Systems and Pertinent Negatives 159
Guided Exercise 5B: Using Lists and Otherwise Normal 161
Critical Thinking Exercise 5C: Using Syncope List for a TIA Case 166
The Concept of Forms 171
Comparison of Lists and Forms 172
Initial Intake Form for an Adult 172
Guided Exercise 5D: Using Forms 172
Customized Forms 182
Real-Life Story: How I Learned to Stop Worrying and Love Forms 183
Critical Thinking Exercise 5E: Using a Form and a List 184
Chapter Five Summary 190
Testing Your Skill Exercise 5F: A Patient with Dyspnea 192

Chapter 6. Understanding Electronic Orders 194
The Importance of Electronic Orders and Results 194
Recording Orders in the Student Edition 195
Learning to Use the Search and Prompt Features 196
How Search Works 197
Guided Exercise 6A: Using Search and Prompt, and Ordering Tests 197
Moving Concepts and Findings to a Different Section 199
Merge Prompt–Intelligent Prompting 200
Lab Orders and Reports 204
Workflow of Electronic Lab Orders and Results 207
Guided Exercise 6B: Ordering an X-Ray 209
Radiology Orders and Reports 213
Workflow of Radiology Orders 214
Critical Thinking Exercise 6C: Ordering Tests and an X-Ray 216
Protocols Based on Diagnosis 220
Primary and Secondary Diagnoses 220
Multiple Diagnoses 220
The Rule-Out Diagnosis 220
Using Symptoms and History to Prompt for Findings 221
Guided Exercise 6D: Patient With Multiple Diagnoses 221
Medication Orders 229
Electronic Prescriptions 230
Closing the Loop on Safe Medication Administration 231
Guided Exercise 6E: Writing Prescriptions in an EHR 232
Quick Access to Frequent Orders 237
Guided Exercise 6F: Ordering Medications Using Discharge Orders 238
Real-Life Story: When Orders and Results
Are Critical 239
Chapter Six Summary 243
Testing Your Skill Exercise 6G: Discharging a Patient with Deep Vein Thrombosis 244

Comprehensive Evaluation of Chapters 1—6 246

Part I—Testing Your Knowledge of Chapters 1—6 246
Part II—Guided Exercise CE1: Document Image Retrieval 246
Part III—Critical Thinking Exercise CE2: ER Visit for Shortness of Breath 247

Chapter 7. Problem Lists, Lab Results, and Body Mass Index 254

Longitudinal Patient Records to Manage Patients’ Health 254
Understanding Problem Lists 255
The Problem-oriented Chart 257
Guided Exercise 7A: Working With a Problem-oriented Chart 257
Citing Previous Encounter Data 266
Guided Exercise 7B: Adding Problems, Retrieving and Citing Lab Results 266
Orders and Results Management 276
Guided Exercise 7C: Retrieving Pending Lab Results 277
Critical Thinking Exercise 7D: Using Lab Results to Rule Out Lead Poisoning 280
Body Mass Index 284
Real-Life Story: Experiencing the Functional Benefits of an EHR 285
Waist Circumference and BMI 287
Critical Thinking Exercise 7E: Determining BMI Category for a Patient 288
Guided Exercise 7F: Calculating BMI and Trending Weight for a Diabetic Patient 289
Critical Thinking Exercise 7G: Discovering Your BMI and Category 294
Chapter Seven Summary 295
Testing Your Skill Exercise 7H: Patient with Upper Abdominal Chest Pain 297

Chapter 8. Flow Sheets, Annotated Drawings, and Graphs 300
Learning to Use Flow Sheets 300
Guided Exercise 8A: Working with a Flow Sheet 301
About the Flow Sheet View 301
Guided Exercise 8B: Obstetric Patient’s Flow Sheet 308
Critical Thinking Exercise 8C: Flow Sheet with Multiple Diagnoses 316
Use of Anatomical Drawings in the EHR 320
Navigation by Body System 320
Annotated Drawings as EHR Data 321
Guided Exercise 8D: Annotated Dermatology Exam 321
Critical Thinking Exercise 8E: Examination of a Patient with Pressure Sores 330
Real-Life Story: First Patient Whose Life Was Saved by Expert System Software He Operated Himself 331
Using Graphs to View Trends 337
Visual Aids to Engage Patients in Their Own Healthcare 338
Guided Exercise 8F: Trending with a Graph and Flow Sheet 338
Critical Thinking Exercise 8G: Graphing Weight and BMI 341
Chapter Eight Summary 343
Testing Your Skill Exercise 8H: Diabetic with High Blood Pressure 345

Chapter 9. Using the EHR to Improve Patient Health 347

Prevention and Early Detection 347
Pediatric Wellness Visits 348
Guided Exercise 9A: Well-Baby Checkup 348
Understanding Growth Charts 354
What Is a Percentile? 356
CDC Growth Charts 356
Guided Exercise 9B: Pediatric Vitals and Growth Charts 358
The Importance of Childhood Immunizations 362
Guided Exercise 9C: Reviewing and Ordering Vaccines 362
Critical Thinking Exercise 9D: Determine Your Adult Immunizations 367
Preventative Care Screening 369
Clinical Quality Measures 369
Real-Life Story: Quality Care for Pediatric and Adult Patients 370
Guided Exercise 9E: Applying Quality Measures to Patient Care 371
About the Quality Measures Review 373
Critical Thinking Exercise 9F: Clinical Quality Measures for a Female Patient 377
The Patient-Centered Medical Home 382
Chapter Nine Summary 383
Testing Your Skill Exercise 9G: Baby’s First Checkup 384

Chapter 10. Decision Support and Patient Involvement 386
Enriching the EHR Through Connectivity 386
Decision Support 387
Integrated Decision Support 388
Guided Exercise 10A: Patient with Dengue Fever 389
Critical Thinking Exercise 10B: Accidental Exposure to Paraquat 395
Patient Involvement in Their Own Healthcare 398
Patient Education Material 400
Guided Exercise 10C: Patient Education
About Risk of COPD 400
Critical Thinking Exercise 10D: Patient Education About Diabetes 405
Using the Internet 409
Critical Thinking Exercise 10E: Internet Medical Research 409
Secure Internet Data 410
Remote EHR Access for the Provider 412
Practicing Medicine Online 412
Asynchronous Telemedicine at Mayo Clinic 413
Teleradiology 414
Telemedicine in Nursing 414
Telemedicine via E-Visits 415
Patient Entry of Symptoms and History 416
Workflow Using Patient-Entered Data 416
Internet Workflow 417
Improved Patient Information 418
Guided Exercise 10F: Experiencing Patient-Entered HPI 418
Guided Exercise 10G: Reviewing Patient-Entered Data 425
E-Visits 427
Real-Life Story: Using the Internet to Build a Patient-Centered Practice 428
Mayo Clinic Study of E-visits 430
E-Visits in Practice 431
Workflow of an E-Visit 431
Guided Exercise 10H: Patient Requests an E-Visit 432
Critical Thinking Exercise 10J: Clinician Completes the E-Visit 435
Patient Access to Electronic Health Records 438
Chapter Ten Summary 438
Testing Your Skills Exercise 10K: A Patient with Hepatitis A 440

Chapter 11. Privacy and Security of Health Records 443
Understanding HIPAA 442
Administrative Simplification Subsection 443
HIPAA Transactions and Code Sets 443
HIPAA Transactions 443
Standard Code Sets 444
HIPAA Uniform Identifiers 444
HIPAA Privacy Rule 445
Privacy Policy 446
Consent 447
Modifying HIPAA Consent 448
Critical Thinking Exercise 11A: Creating a Privacy Policy 449
Authorization 449
Research 450
Research Exceptions 450
Marketing 450
Guided Exercise 11B: Authorization for Release of PHI 450
Government Agencies 452
Minimum Necessary 452
Incidental Disclosures 453
A Patient’s Right to Know About Disclosures 453
Patient Access to Medical Records 453
Personal Representatives 454
Minor Children 454
Critical Thinking Exercise 11C: What Is Required? 455
Business Associates 456
Electronic Health Information Exchange 456
Real-Life Story: The First Hipaa Privacy Case 457
Civil and Criminal Penalties 457
HIPAA Security Rule 458
Why a Security Rule? 458
The Privacy Rule and Security Rule Compared 459
Critical Thinking Exercise 11D: Comparing Privacy and Security Rules 459
Security Standards 459
Implementation Specifications 460
Administrative Safeguards 460
Security Management Process 460
Critical Thinking Exercise 11E: How to Assess Security Risk 461
Assigned Security Responsibility 463
Workforce Security 463
Information Access Management 464
Security Awareness and Training 464
Security Incident Procedures 465
Contingency Plan 466
Evaluation 466
Critical Thinking Exercise 11F: Developing a Contingency Plan 466
Real-Life Story: Contingency Plans Ensure Continued Ability to Deliver Care 467
Business Associate Contracts and Other Arrangements 466
Physical Safeguards 467
Facility Access Controls 468
Workstation Use 468
Workstation Security 468
Device and Media Controls 468
Technical Safeguards 469
Access Control 469
Audit Controls 470
Integrity 470
Person or Entity Authentication 470
Transmission Security 471
Organizational, Policies and Procedures, and Documentation Requirements 471
Organizational Requirements 471
Policies and Procedures 472
Documentation 472
Minimizing the Risk of Mobile Devices 472
Critical Thinking Exercise 11G: Securing EHR Access 473
Breach Notification Requirements 473
Individual Notice 473
Media Notice 474
Notice to the Secretary 474
Notification by a Business Associate 474
Electronic Signatures for Health Records 474
HIPAA Privacy, Security, and You 475
Chapter Eleven Summary 475

Chapter 12. EHR Coding and Reimbursement 479
The EHR and Reimbursement 479
HIPAA-Required Code Sets 480
Diagnoses Codes Justify Billing 480
Primary and Secondary Diagnoses 481
Multiple Diagnoses 481
Guided Exercise 12A: Using Code Review 481
CPT-4 and HCPCS Codes 485
Evaluation and Management (E&M) Codes 485
Four Levels of E&M Codes 486
How the Level of an E&M Code Is Determined 486
Undercoding 486
Accurate Coding 488
Using EHR Software to Understand E&M Codes 488
Guided Exercise 12B: Calculating the E&M Code from an Encounter 488
Key Components 491
Levels of Key Components 491
Key Component: History 491
Key Component: Examination 495
Guided Exercise 12C: Understanding the Examination Component 496
Levels of Key Component: Examination 500
Key Component: Medical Decision Making 502
Guided Exercise 12D: Understanding the MDM Component 503
Determining the Level of Medical Decision Making 506
Other Components: Counseling, Coordination of Care, and Time 508
Putting It All Together 510
Evaluating Key Components 510
How Changes in Key Components Affect the E&M Code 511
Guided Exercise 12E: Calculating E&M for a More Complex Visit 512
Guided Exercise 12F: Counseling Over 50 Percent of Face-to-Face Time 518
Critical Thinking Exercise 12G: Understanding How Procedures Are
Posted to the Billing System 521
Real-Life Story: A New Level of Efficiency in Addition to Improved E&M Coding 525
Factors That Affect the E&M Code Set 526
Guided Exercise 12H: Exploring Other Factors of E&M Codes 526
Clinical Setting 530
Detailed Service Type 530
Exam Type 530
Chapter Twelve Summary 532
Testing Your Skill Exercise 12J: Counseling an Established Patient 533

Comprehensive Evaluation of Chapters 7—12 535

Part I–Testing Your Knowledge of Chapters 7—12 535
Part II–Critical Thinking Exercise CE3: Examination of a Patient with Arterial Disease 535
Part III–Critical Thinking Exercise CE4: Counseling and Education for a Patient with Arterial Disease 538
Part IV–Testing Your Skill Exercise CE5: Patient Signs HIPAA Authorization 540

Glossary 542
Index 552
Acronyms 568

Rewards Program

Write a Review