Electronic Health Records: Understanding and Using Computerized Medical Records
Richard W. Gartee

ISBN-10: 0131960792
ISBN-13: 9780131960794

Publisher: Prentice Hall
Copyright: 2007
Format: Paper; 544 pp
Published: 04/07/2006

Suggested retail price: $81.60
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Electronic Health Records, a foundational course in Health Information Management or Health Information Technology programs prepares students to understand and use electronic records in a medical practice. Gartee's, first of its kind, "how to" text is designed to train future users of EHR programs, to document patient exam, diagnosis, orders, and coding. It contains screen shots, exercises and activities to provide a complete learning system. Written for everyone in the office who will touch the electronic medical record, course material is suitable for medical and nursing schools, allied health career schools, universities, community colleges and continuing education programs.

 

ABOUT THE SOFTWARE : 

The Student CD that accompanies the book, can be networked, used for distance learning, or purchased individually or as a val pak with the book. The software does not come bound in the book.  Instructors will receive a copy of the Medcin Software which is bound into the instructors manual by contacting their local representative.

The Medcin Student Edition Software may be value packed with Richard Gartee's Electronic Health Records - ISBN: 0131564862  for $10.00 more than the price of the text or as a stand alone Student CDROM - ISBN:0131789376 available from Prentice Hall.

 

The software is multi-user allowing students to work simultaneously and keep work separate.  Excercise print outs generated from Medcin automatically include the student's login name or ID.  Medcin is the licensed core technology in many prominent EHR Systems.  10 out of 15 EHR systems for medical offices use Medcin nomenclature as the  technology underlying commercial EHR systems.  Students therefore are more likely to apply skills acquired in this course to an EHR application in their office.

  • All work is printed and no excercises require saving.
  • All excercises are designed to be completed during a normal class time.
  • Printers use a standard Windows system.
  • For distance learning, the software allows the student to "Print to HTML" which will output the exercise document into a file that can be emailed.

 

Does your current text train users of EHR systems?

  • Cutting edge text written for the student to learn how to use Electronic Health Records.

 How do you provide your students with hands on experience?

  •  Electronic Health Records Software that is incorporated into the text to give students hands on experience that is crucial to their future success.

 How do you reinforce the material learned in each chapter?

  • Chapter Tutorials that fill the center of the text, allowing students to learn the material in a step by step format.

 What role do real-life experiences play in your teaching of the subject?

  • True Story vignettes, all about working with electronic health records bringing the subject to life.

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

Chapter 1 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

Where’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

Chapter One Summary

 

Chapter 2 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

Chapter Two Summary

 

Chapter 3 Learning Medical Record Software

Introducing The Medcin Student Edition

Understanding The Software

Hands On Exercise 1: Starting Up The Medcin Software

Navigating The Screen

Hands On Exercise 2: Exiting And Re-Starting The software

Hands On Exercise 3: Using The Menu to Select A Patient

Hands On Exercise 4: Navigating The Medcin Findings

Hands On Exercise 5: Tabs On The Medcin Nomenclature Panel

Data Entry Of The Examination Note

Hands On Exercise 6: Creating An Encounter

Hands On Exercise 7: Recording Subjective Findings

Hands On Exercise 8: Removing Findings

Hands On Exercise 9: Recording More Specific Findings

Hands On Exercise 10: Recording History Findings

Adding Details To The Findings

Hands On Exercise 11: Recording A Value

Using Free Text

Hands On Exercise 12: Adding Free-text

Hands On Exercise 13: Recording Objective Findings

Hands On Exercise 14: Setting The Result Field

Hands On Exercise 15: Adding Detail To Recorded Findings

Hands On Exercise 16: Adding Episode Detail To Findings

Hands On Exercise 17: Recording The Assessment

Hands On Exercise 18: Recording Treatment Plan And Physician Orders

Introduction To Using Forms

Hands On Exercise 19: Recording The Chief Complaint

Hands On Exercise 20: Recording Vital Signs

Paperless In Less Than A Day — A Real Life Story

Applying Your Knowledge

Hands On Exercise 21: Documenting A Visit For Headaches

Hands On Exercise 22: Printing The Narrative Report

Chapter Three Summary

Chapter 4 Data Entry At The Point Of Care

Increased Familiarity With The Software

Documenting A Brief Patient Visit

Hands On Exercise 23: Documenting A Visit For A Common Cold

Why Speed of Entry Is Important In The EHR

Methods To Increase Speed of Entry

Encounter Tab Toolbar

Search and Prompt Features

How Search Works

            Hands On Exercise 24: Using Search

            Hands On Exercise 25: Ordering Diagnostic Tests

Shortcuts That Increase Speed For Routine Exams

The Concept of Lists

Hands On Exercise 26: Using Adult URI List

Hands On Exercise 27: Writing Prescriptions In An EHR

Hands On Exercise 28: Timed Experiment For Extra Credit

The Concept Of Forms

Standard Initial Visit Intake For Adult

Hands On Exercise 29: Using Forms

How I Learned To Stop Worrying And Love Forms — A Real Life Story

Chapter Four Summary

Chapter 5 Electronic Coding From Medical Records

CPT-4 and ICD-9CM Codes For Billing

Understanding Evaluation And Management Codes

Using EHR Software to Calculate The Correct E&M Code

Hands On Exercise 30: Calculating E&M Code From An Exam

How The Level of An E&M Code Is Determined

Key Component: History

How History May Be Documented

Key Component: Examination

Key Component: Medical Decision Making

Determining The Level of Medical Decision Making

Other Components: Counseling, Coordination of Care, And Time

Putting It All Together

            Evaluating Key Components

Factors That Affect The E&M Code Set

Hands On Exercise 31: Exploring The E&M Calculator

Factors That Increase The Level of Codes

Fraud And Abuse

Hands On Exercise 32: Calculating E&M For A More Complex Visit

Hands On Exercise 33: Counseling More Than 50% Of Face-to-Face Time

A New Level Of Efficiency In Addition To Improved E&M Coding — A Real Life Story

ICD-9CM Codes Justify Billing

Determine The Level of Specificity

Multiple Diagnosis Codes Per Visit

Primary And Secondary Diagnoses

Medical Necessity

Ordering Tests to Confirm or Rule Out Diagnosis

How The ICD-9 Code Influences Orders And Treatment

            Hands On Exercise 34: Orders Based On Diagnosis

Hands On Exercise 35: Multiple Diagnoses

Chapter Five Summary

 

Comprehensive Evaluation of Chapters 1-5

Hands On Exercise 36: Examination of A Patient With Asthma

Chapter 6 Advanced Techniques Speed Data Entry

Important Information About The Student Edition Patient History Program

Improved Data Entry

Management of Patients’ Health

Understanding Problem Lists

Hands On Exercise 37: Exploring Patient Management

Citing Previous Visits From Problem Lists

Hands On Exercises 38: Following Up On A Problem

EHR Data From External Sources

Vitals Signs

Diagnostic Tests

Electronic Lab Orders and results

Work Flow of Electronic Lab Orders And Results

            Hands On Exercise 39: Viewing Pending Orders and Lab Results

Graphing Lab Results From The Chart

Hands On Exercise 40: Graphing Lab Results

Quick Access To Frequent Orders

Patient Entry of Symptoms and Previous History

Triage

The Clinicians’ Dilemma

Triage by Computer

Workflow Using Patient Entered Data

Alternative Workflow

Improved Patient Information

Preventive Health Screening

Systems Integration For Better Patient Care

The First Patient Whose Life Was Saved By Expert System Software He Operated Himself — A Real Life Story

Chapter Six Summary

Chapter 7 Using The EHR to Improve Patient Care

Disease Management and Prevention

Flow Sheets

Hands On Exercise 41: Working With A Flow Sheet

About The Flow Sheet View

Hands On Exercise 42: Creating A Problem Oriented Flow Sheet

Patient Involvement In Their Own Health Care

Hands on Exercise 43: Graphing Vital Signs In The Chart

Patient Entered Data Graphs

Prevention and Early Detection

Pediatric Wellness Visit

            Hands On Exercise 44: A Well-Baby Check Up

The Relation Between Vitals and Growth Charts

What is a Percentile?

Body Mass Index

            Optional Exercise 45: Calculate Your Own BMI

The Importance of Childhood Immunizations

Hands On Exercise 46: Immunizations

Immunization Schedules From The CDC

Optional Exercise 47: Determine Your Adult Immunizations

Preventative Care Screening

Quality Care For Pediatric And Adult Patients - A Real Life Story

Using EHR Data For Alerts

Reactions to Drugs or Other Treatments

Other Types of Alerts

Chapter Seven Summary

 

Chapter 8 Privacy and Security of Health Records

Understanding HIPAA

HIPAA Transactions And Code Sets

HIPAA Uniform Identifiers

HIPAA Privacy Rule

Privacy Policy

Consent

Authorization

Government Agencies

Minimum Necessary

A Patient’s Right To Know About Disclosures

Patient Access To Medical Records

Indirect Disclosures

Personal Representatives

Minor Children

Summary of Patient Privacy Rights

Business Associates

Civil And Criminal Penalties

The First HIPAA Privacy Case — A Real Life Story

HIPAA Security Rule

Why Security?

Privacy Rule And Security Rule Compared

Security Standards

Implementation Specifications

Administrative Safeguards

Security Management Process

Assigned Security Responsibility

Workforce Security

Information Access Management

Security Awareness And Training

Security Incident Procedures

Contingency Plan

Evaluation

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

Electronic Signatures For Medical Records

What Is An Electronic Signature And What Is Not

How Digital Signatures Work

Some An Electronic Signatures Are Not Truly Signatures

The Future Of Electronic Signatures

HIPAA Privacy, Security, And You

Hands On Exercise 48: Medical Office Privacy Policy

Chapter Eight Summary

 

Chapter 9 EHR And Technology

How Technology Impacts Implementation of EHR

Style of Practice

Physical Clinic And Clinician Mobility

EHR On Computer Workstations

EHR On Laptop Computers

EHR On A Tablet PC

EHR On Handheld PDA Devices

How Wireless Networks Work

EHR Devices And The Patient

Remote EHR Access For The Provider

Enhancing Process Efficiency Through Remote Access — A Real Life Story

Speech Recognition

How Speech Recognition Software Works

Including Annotated Drawings In EHR

            Hands On Exercise 49: Annotated Dermatology Exam

Internet And The EHR

Decision Support

Provider-to-Patient E-Mail Communication

Secure Messaging

E-Visits

Workflow of An E-Visit

Patient Access to Electronic Health Records

            Optional Exercise 50: Creating Your Own Health Record

Chapter Nine Summary

 

Comprehensive Evaluation of Chapters 6-9

Hands On Exercise 51: Examination of A Patient With Arterial Disease

 

Appendix A - CMS Documentation Guideline Tables

General Multi-system Examination

ENT Examination

Appendix B - Information About The Student Edition History Program

Instructions for Starting History Program Software

Stopping The History Program

Indications That The History Program Is Not Running

 

 

Glossary

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.

 

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