Electronic Health Records

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1 Electronic Health Records third edition Byron R. Hamilton CEO, Med-Soft National Training Institution Colorado, BA, MA Connect Mc \ Learn Graw 1 Succeed'' Hill

2 table of contents ABOUT THE AUTHOR iii PREFACE xi What You Can Expect in Electronic Health Records, Third Edition xi Organization of Electronic Health Records, 3e xi What's New in the Third Edition of EHR? xi To the Instructor xii To the Student xiii ACKNOWLEDGMENTS xv Workshops Book Reviews xv xv Technical Edit/Accuracy Panel xvi Digital Resources xvi Acknowledgments from the Author xvi WALKTHROUGH xviii A COMMITMENT TO ACCURACY xx Chapter 1 The Electronic Health Record 1 Outcomes 1 What You Need to Know 1 Terms 1 Introduction Overview of the Electronic Health Record 2 The Concept 2 EHR Models History of the Electronic Health Record EHR Terminology Government Involvement in the EHR 10 Medicare Improvements for Patients and Providers Act of American Recovery and Reinvestment Act of Beacon Community Program 11 Regional Extension Centers Healthcare Processes and the EHR Barriers and Benefits of the EHR 16 Barriers to the EHR 16 Benefits of the EHR The Future of the Electronic Health Record 21 Chapter 1 Summary 23 Chapter 1 Review 25 UsingTerminology 25 Checking Your Understanding 25 ApplyingYour Knowledge 27 Chapter 2 Standards and Features of Electronic Health Records 28 Outcomes 28 What You Need to Know 28 Terms 28 Introduction History of EHR Standards 29 Health Insurance Portability and Accountability Act(HTPAA) 29 Consolidated Health Information (CHI) 29 Institute of Medicine (IOM) 30 The Certification Commission for Health Information Technology (CCHTT) 31 Office of the National Coordinator for Health Information Technology (ONC) EHR Functionality 33 Meaningful Use (MU) 33 Computerized Entry (CPOE) 39 Provider Order 2.3 Privacy and Security of the EHR 40 USA PATRIOT Act and Homeland Security 40 HTPAA and Privacy/Security 41 The Health Information Technology for Economic and Clinical Health (HITECH) Act 42 Other Privacy Concerns EHR Implementation and Technology 44 V

3 2.5 Electronic Health Record Competencies 45 Chapter 2 Summary 47 Chapter 2 Review 49 UsingTerminology 49 Checking Your Understanding 49 Applying Your Knowledge 51 Chapter 3 Introduction and Setup 54 Outcomes 54 WhatYou Need to Know 54 Terms 54 Introduction The Story of SpringCharts EHR Software and Its Features 55 Development of SpringCharts 55 Clinical Tools 57 Administrative Took 57 Certification and Meaningful Use Criteria 57 Privacy and Security User Preferences 60 Preferences! 60 Preferences 2 63 Password 64 Signature 64 3 EHR Exercise Address Data Setup 66 New Address 66 Editing Addresses 68 & EHR Exercise & EHR Exercise EHR Exercise & EHR Exercise & EHR Exercise & EHR Exercise Patient Data Setup 72 New Patient 73 Editing Patients 75 3 EHR Exercise EHRExerci$e & EHR Exercise Insurance Data Setup 77 New Insurance Company 78 Editing Insurance Information 78 & EHR Exercise & EHR Exercise Chapter 3 Summary 80 Chapter 3 Review 81 Using Terminology 81 Checking Your Understanding 82 Applying Your Knowledge 83 Chapter 4 The Clinic Administration 84 Outcomes 84 What You Need to Know 84 ' Terms 84 Introduction The Practice View Screen 85 3 EHR Exercise Appointment Schedule 87 & EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise Patient Tracker 93 Color Coding 94 Location and Status 95 Tracker Group 96 Patient Info 96 Check out 97 Tracker Archive 98 3 EHR Exercise EHR Exercise EHR Exercise EHRExercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise vi -

4 ff EHR Exercise ff EHR Exercise To Do Lists and Reminders 102 My ToDo List 103 ff EHR Exercise ff EHR Exercise ff EHR Exercise ff EHR Exercise Internal Messages 105 Nonpatient Messages 105 Messages Concerning Patients 107 ff EHR Exercise ff EHR Exercise ff EHR Exercise Urgent Messages 111 ff EHR Exercise ff EHR Exercise ff EHR Exercise Chapter 4 Summary 113 Chapter 4 Review 114 Using Terminology 114 Checking Your Understanding 114 Applying Your Knowledge 116 Chapter 5 The Patient Chart 117 Outcomes 117 What You Need to Know 117 Terms 117 Introduction Overview of the Patient Chart 118 Face Sheet 120 Care Tree 121 ff EHR Exercise Creating Allergies 123 Social History 125 a Face Sheet 123 Past Medical History (PMHX) 126 Family Medical History (FMHX) 127 Referrals 127 Chart Note 128 Routine Medications 129 Outside Medications 131 Problem List 131 Chart Alert 133 Patient Annotations 133 Patient Requests 133 Saving and Printing 134 ff EHR Exercise Procedures in a Patient's Chart 136 Adding the Primary Insurance 136 Entering Past Immunizations 137 Graphing Vital Signs 138 ff EHR Exercise ff EHR Exercise New Activities in a Patient's Chart 140 New TC Note 140 New Vitals Only 141 New Letter to the Patient 143 New Letter about a Patient 144 New Test Report to the Patient 145 New Excuse/Note/Order 147 ff EHR Exercise ff EHR Exercise ff EHR Exercise Chapter 5 Summary 150 Chapter 5 Review 151 UsingTerminology 151 Checking Your Understanding 151 ApplyingYour Knowledge 152 Chapter 6 The Office Visit 153 Outcomes 153 What You Need to Know 153 Terms 153 Introduction Components of the Office Visit Building an Office Visit Note 1 Overview 156 Chief Complaint, Present Illness, Review of Systems, and Exam 156 Face Sheet 158 Vitals 158 Diagnosis 159

5 Prescriptions 159 Tests 163 Procedures 164 Other Treatment 165 Follow-up 165 Signing and Dating B EHR Exercise an OV Note 166 B EHR Exercise B EHR Exercise Activities within the Office Visit Screen 169 Editing the Patient's Face Sheet 169 Modifying and Printing Immunization Record 170 Viewing and Graphing Results 170 Creating Changing an Excuse Note 171 the Chart Tab 172 & EHR Exercise B EHR Exercise Routing Slip 174 & EHR Exercise Adding the Patient's the Patient's Lab Addenda to an Office Visit Note 178 B EHR Exercise Office Visit Reports 180 Examination Report to Patient 180 Office Visit (SOAP) Note 181 History and Physical Report 182 Office Visit Template Reports 182 B EHR Exercise B EHR Exercise B EHR Exercise Chapter 6 Summary 186 Chapter 6 Review 187 UsingTerminology 187 Checking Your Understanding 187 Applying Your Knowledge 188 Chapter 7 Clinical Tools 189 Outcomes 189 What You Need to Know 189 Terms 189 Introduction Chart Evaluation 190 B EHR Exercise Test Orders 196 B EHR Exercise Evaluation JL Management Coder 199 B EHR Exercise Superbill Form 201 B EHR Exercise Patient Instructions 202 B EHR Exercise B EHR Exercise Care Plans and Practice Guidelines 207 B EHR Exercise Drawing Program Importing Documents 210 B EHR Exercise Chapter 7 Summary 216 Chapter 7 Review 217 Using Terminology 217 Checking Your Understanding 218 Applying Your Knowledge 219 Chapter 8 Creating Templates 220 Outcomes 220 What You Need to Know 220 Terms 220 Introduction Creating Templates 221 Office Visit B EHR Exercise B EHR Exercise Creating Physician Order Templates 224 B EHR Exercise Creating Letter Templates 228 B EHR Exercise viii

6 8.4 Template Manager 230 & EHR Exercise Creating Procedure Templates 231 & EHR Exercise Chapter 8 Summary 234 Chapter 8 Review 234 Using Terminology 234 CheckingYour Understanding 235 Applying Your Knowledge 236 Chapter 9 Tests, Procedures, and Codes 237 Outcomes 237 What You Need to Know 237 Terms 237 Introduction Ordering a Test 238? EHR Exercise & EHR Exercise SpringLabs Lab Results 240 Access Stored Data 241 and Reference Manage Test Name Synonyms 242 Matching 243 Force Entering and Deleting 244 i? EHR Exercise Processing and Charting Tests 246 & EHR Exercise & EHR Exercise Creating a Test Report 252 & EHR Exercise Documenting, Activating, and Editing Procedure Codes 254 Documenting a Procedure 255 Creating a New Procedure 255 Creating an Iinmunization Procedure 257 Editing a Procedure 258 & EHR Exercise Documenting, Activating, and Editing Diagnosis Codes 260 Documenting a Diagnosis 260 Creating a New Diagnosis 261 Editing a Diagnosis 262 ICD-10 Codes EHR Exercise &EHRExercise Chapter 9 Summary 266 Chapter 9 Review 267 UsingTerminology 267 Checking Your Understanding 267 ApplyingYour Knowledge 269 Chapter 10 Productivity Center and Utilities 270 Outcomes 270 What You Need to Know 270 Terms 270 Introduction Bulletin Board EHR Exercise Integrated Faxing 273 Outbound Fax History 274 Inbound Fax List 274 iff EHR Exercise Time Clock 276 iff EHR Exercise My Websites 278 iff EHR Exercise Calculators 279 Conversion Calculator 280 Pregnancy Simple Calculator 280 EDD Calculator 280 S EHR Exercise Patient Database Reporting 281 Form Letters 284 Reports 284 iff EHR Exercise Patient Archive 287 iff EHR Exercise Chapter 10 Summary 289 Chapter 10 Review 290 Using Terminology 290 CheckingYour Understanding 291 ApplyingYour Knowledge 292 ix

7 Chapter 11 Applying Your Knowledge 293 Outcomes 293 What You Need to Know 293 Introduction Practice View Screen 294 Office Schedule EHR Exercise EHR Exercise Patient Tracker EHR Exercise EHR Exercise EHR Exercise To Do List 299 & EHR Exercise EHR Exercise Messages EHR Exercise EHR Exercise EHR Exercise Patient Chart Screen 303 Face Sheet EHR Exercise Patient Chart Activities EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise Office Visit Screen 310 Office Visit Note EHR Exercise EHR Exercise Office Visit Activities EHR Exercise EHR Exercise Chapter 12 EHR Practicum 317 Outcome 317 What You Need to Know 317 Introduction Recording Information from Paper Source Documents EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise EHR Exercise Appendix A: Sample Documents 322 Appendix B: Source Documents for SpringCharts Single-User Version 337 Appendix C: Exercises for the Networked Computer Environment 347 Appendix D: Source Documents for SpringCharts Network Version 414 Glossary 424 Notes 430 Index 431 x Copyright 2013 by The McGraw-Hill Companies. Inc.

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