Electronic Health Records third edition Byron R. Hamilton CEO, Med-Soft National Training Institution Colorado, BA, MA Connect Mc \ Learn Graw 1 Succeed'' Hill
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 2 1.1 Overview of the Electronic Health Record 2 The Concept 2 EHR Models 4 1.2 History of the Electronic Health Record 6 1.3 EHR Terminology 7 1.4 Government Involvement in the EHR 10 Medicare Improvements for Patients and Providers Act of 2008 9 American Recovery and Reinvestment Act of 2009 9 Beacon Community Program 11 Regional Extension Centers 11 1.5 Healthcare Processes and the EHR 12 1.6 Barriers and Benefits of the EHR 16 Barriers to the EHR 16 Benefits of the EHR 17 1.7 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 29 2.1 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) 32 2.2 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 43 2.4 EHR Implementation and Technology 44 V
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 55 3.1 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 59 3.2 User Preferences 60 Preferences! 60 Preferences 2 63 Password 64 Signature 64 3 EHR Exercise 3.1 65 3.3 Address Data Setup 66 New Address 66 Editing Addresses 68 & EHR Exercise 3.2 69 & EHR Exercise 3.3 69 3 EHR Exercise 3.4 69 & EHR Exercise 3.5 70 & EHR Exercise 3.6 70 & EHR Exercise 3.7 70 3.4 Patient Data Setup 72 New Patient 73 Editing Patients 75 3 EHR Exercise 3.8 77 3EHRExerci$e3.9 77 & EHR Exercise 3.10 77 3.5 Insurance Data Setup 77 New Insurance Company 78 Editing Insurance Information 78 & EHR Exercise 3.11 79 & EHR Exercise 3.12 79 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 85 4.1 The Practice View Screen 85 3 EHR Exercise 4.1 87 4.2 Appointment Schedule 87 & EHR Exercise 4.2 91 8 EHR Exercise 4.3 91 3 EHR Exercise 4.4 91 3 EHR Exercise 4.5 91 3 EHR Exercise 4.6 92 3 EHR Exercise 4.7 92 3 EHR Exercise 4.8 92 3 EHR Exercise 4.9 92 4.3 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 4.10 99 3 EHR Exercise 4.11 99 3 EHR Exercise 4.12 99 3EHRExercise4.13 99 3 EHR Exercise 4.14 100 3 EHR Exercise 4.15 100 3 EHR Exercise 4.16 100 3 EHR Exercise 4.17 100 3 EHR Exercise 4.18 101 3 EHR Exercise 4.19 101 vi -
ff EHR Exercise 4.20 101 ff EHR Exercise 4.21 101 4.4 To Do Lists and Reminders 102 My ToDo List 103 ff EHR Exercise 4.22 104 ff EHR Exercise 4.23 104 ff EHR Exercise 4.24 104 ff EHR Exercise 4.25 105 4.5 Internal Messages 105 Nonpatient Messages 105 Messages Concerning Patients 107 ff EHR Exercise 4.26 109 ff EHR Exercise 4.27 109 ff EHR Exercise 4.28 110 4.6 Urgent Messages 111 ff EHR Exercise 4.29 112 ff EHR Exercise 4.30 112 ff EHR Exercise 4.31 112 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 118 5.1 Overview of the Patient Chart 118 Face Sheet 120 Care Tree 121 ff EHR Exercise 5.1 122 5.2 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 5.2 134 5.3 Procedures in a Patient's Chart 136 Adding the Primary Insurance 136 Entering Past Immunizations 137 Graphing Vital Signs 138 ff EHR Exercise 5.3 139 ff EHR Exercise 5.4 139 5.4 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 5.5 148 ff EHR Exercise 5.6 148 ff EHR Exercise 5.7 149 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 154 6.1 Components of the Office Visit 154 6.2 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
Prescriptions 159 Tests 163 Procedures 164 Other Treatment 165 Follow-up 165 Signing and Dating B EHR Exercise 6.1 167 an OV Note 166 B EHR Exercise 6.2 168 B EHR Exercise 6.3 169 6.3 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 6.4 173 B EHR Exercise 6.5 173 6.4 Routing Slip 174 & EHR Exercise 6.6 177 6.5 Adding the Patient's the Patient's Lab Addenda to an Office Visit Note 178 B EHR Exercise 6.7 178 6.6 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 6.8 184 B EHR Exercise 6.9 185 B EHR Exercise 6.10 185 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 190 7.1 Chart Evaluation 190 B EHR Exercise 7.1 196 7.2 Test Orders 196 B EHR Exercise 7.2 198 7.3 Evaluation JL Management Coder 199 B EHR Exercise 7.3 200 7.4 Superbill Form 201 B EHR Exercise 7.4 201 7.5 Patient Instructions 202 B EHR Exercise 7.5 206 B EHR Exercise 7.6 207 7.6 Care Plans and Practice Guidelines 207 B EHR Exercise 7.7 209 7.7 Drawing Program 209 7.8 Importing Documents 210 B EHR Exercise 7.8 216 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 221 8.1 Creating Templates 221 Office Visit B EHR Exercise 8.1 223 B EHR Exercise 8.2 223 8.2 Creating Physician Order Templates 224 B EHR Exercise 8.3 227 8.3 Creating Letter Templates 228 B EHR Exercise 8.4 229 viii
8.4 Template Manager 230 & EHR Exercise 8.5 230 8.5 Creating Procedure Templates 231 & EHR Exercise 8.6 233 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 238 9.1 Ordering a Test 238? EHR Exercise 9.1 240 & EHR Exercise 9.2 240 9.2 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 9.3 245 9.3 Processing and Charting Tests 246 & EHR Exercise 9.4 250 & EHR Exercise 9.5 251 9.4 Creating a Test Report 252 & EHR Exercise 9.6 254 9.5 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 9.7 259 9.6 Documenting, Activating, and Editing Diagnosis Codes 260 Documenting a Diagnosis 260 Creating a New Diagnosis 261 Editing a Diagnosis 262 ICD-10 Codes 262 5 EHR Exercise 9.8 264 &EHRExercise9.9 265 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 271 10.1 Bulletin Board 271 6 EHR Exercise 10.1 273 10.2 Integrated Faxing 273 Outbound Fax History 274 Inbound Fax List 274 iff EHR Exercise 10.2 275 10.3 Time Clock 276 iff EHR Exercise 10.3 278 10.4 My Websites 278 iff EHR Exercise 10.4 279 10.5 Calculators 279 Conversion Calculator 280 Pregnancy Simple Calculator 280 EDD Calculator 280 S EHR Exercise 10.5 281 10.6 Patient Database Reporting 281 Form Letters 284 Reports 284 iff EHR Exercise 10.6 286 10.7 Patient Archive 287 iff EHR Exercise 10.7 288 Chapter 10 Summary 289 Chapter 10 Review 290 Using Terminology 290 CheckingYour Understanding 291 ApplyingYour Knowledge 292 ix
Chapter 11 Applying Your Knowledge 293 Outcomes 293 What You Need to Know 293 Introduction 294 11.1 Practice View Screen 294 Office Schedule 294 8 EHR Exercise 11.1 294 8 EHR Exercise 11.2 296 Patient Tracker 297 8 EHR Exercise 11.3 297 3 EHR Exercise 11.4 297 8 EHR Exercise 11.5 298 To Do List 299 & EHR Exercise 11.6 299 8 EHR Exercise 11.7 300 Messages 301 8 EHR Exercise 11.8 301 8 EHR Exercise 11.9 301 8 EHR Exercise 11.10 301 11.2 Patient Chart Screen 303 Face Sheet 303 8 EHR Exercise 11.11 303 Patient Chart Activities 305 8 EHR Exercise 11.12 305 8 EHR Exercise 11.13 306 8 EHR Exercise 11.14 307 8 EHR Exercise 11.15 307 8 EHR Exercise 11.16 308 8 EHR Exercise 11.17 309 8 EHR Exercise 11.18 309 11.3 Office Visit Screen 310 Office Visit Note 310 8 EHR Exercise 11.19 310 8 EHR Exercise 11.20 311 Office Visit Activities 315 8 EHR Exercise 11.21 315 8 EHR Exercise 11.22 316 Chapter 12 EHR Practicum 317 Outcome 317 What You Need to Know 317 Introduction 318 12.1 Recording Information from Paper Source Documents 318 8 EHR Exercise 12.1 318 8 EHR Exercise 12.2 318 8 EHR Exercise 12.3 318 8 EHR Exercise 12.4 319 8 EHR Exercise 12.5 319 8 EHR Exercise 12.6 319 8 EHR Exercise 12.7 319 8 EHR Exercise 12.8 319 8 EHR Exercise 12.9 319 8 EHR Exercise 12.10 319 8 EHR Exercise 12.11 320 8 EHR Exercise 12.12 320 8 EHR Exercise 12.13 320 8 EHR Exercise 12.14 320 8 EHR Exercise 12.15 320 8 EHR Exercise 12.16 320 8 EHR Exercise 12.17 320 8 EHR Exercise 12.18 321 8 EHR Exercise 12.19 321 8 EHR Exercise 12.20 321 8 EHR Exercise 12.21 321 8 EHR Exercise 12.22 321 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.