• No results found

Electronic Health Records

N/A
N/A
Protected

Academic year: 2021

Share "Electronic Health Records"

Copied!
7
0
0

Loading.... (view fulltext now)

Full text

(1)

Electronic

Health Records

third edition

Byron

R. Hamilton

CEO,

Med-Soft National

Training

Institution—Colorado, BA,

MA

Mc

Graw

Hill

Connect

\

Learn

(2)

table

of

contents

ABOUT THE AUTHOR iii

PREFACE xi

What You CanExpectinElectronicHealthRecords, Third Edition xi

Organizationof Electronic Health Records, 3e xi

What's New in theThirdEdition of EHR? xi

To the Instructor xii To the Student xiii

ACKNOWLEDGMENTS xv

Workshops

xv

Book Reviews xv

Technical

Edit/Accuracy

Panel xvi

Digital Resources xvi

Acknowledgments

from the Author xvi

WALKTHROUGH xviii

ACOMMITMENTTO ACCURACY xx

Chapter

1

The Electronic Health

Record

1

Learning

Outcomes 1

What

You

Need

toKnow 1

Key

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

Barrierstothe EHR 16

Benefits of the EHR 17

1.7 The Future of the Electronic

Health

Record

21

Chapter

1

Summary

23

Chapter

1Review 25

UsingTerminology

25

Checking

Your

Understanding

25

ApplyingYour

Knowledge

27

Chapter

2

Standards and Features of

Electronic

Health Records

28

Learning

Outcomes

28

WhatYouNeedtoKnow 28

Key

Terms 28

Introduction

29

2.1

History

of EHR

Standards

29

Health Insurance

Portability

and

Accountability

Act(HTPAA)

29

Consolidated

Health Information

(CHI)

29

Instituteof Medicine

(IOM)

30

The Certification Commission for

Health

Information

Technology (CCHTT)

31

Office of the National

Coordinator

forHealth

Information

Technology (ONC)

32

2.2 EHR

Functionality

33

Meaningful

Use

(MU)

33

Computerized

Provider

Order

Entry

(CPOE)

39

2.3

Privacy

and

Security

of

the EHR

40

USA

PATRIOT

Actand 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

(3)

2.5

Electronic

Health Record

Competencies

45

Chapter

2

Summary

47

Chapter

2Review 49

Using

Terminology

49

Checking

Your

Understanding

49

Applying

Your

Knowledge

51

Chapter

3

Introduction

and

Setup

54

Learning

Outcomes 54

What

You

Need

to

Know

54

Key

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

3Review 81

Using

Terminology

81

Checking

Your

Understanding

82

Applying

Your

Knowledge

83

Chapter

4

The

Clinic Administration

84

Learning

Outcomes

84

What You Need

toKnow 84 '

KeyTerms

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

EHRExercise 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

(4)

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

4Review 114

Using Terminology

114

Checking

Your

Understanding

114

Applying

Your

Knowledge

116

Chapter

5

The Patient Chart

117

Learning

Outcomes 117

What You NeedtoKnow 117

Key

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

a

Face Sheet

123

Allergies

123

Social

History

125

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

EHRExercise 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

EHRExercise 5.4 139

5.4

New Activities in

a

Patient's

Chart

140

New TC Note 140

New Vitals

Only

141

New

Lettertothe Patient 143

New

Letter

about

aPatient 144

New

Test

Report

tothe Patient 145 New

Excuse/Note/Order

147

ff

EHR Exercise5.5 148

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

Learning

Outcomes

153

What You NeedtoKnow 153

Key

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

(5)

Prescriptions

159

Tests 163

Procedures 164

Other Treatment 165

Follow-up

165

Signing

and

Dating

anOVNote 166

B

EHR Exercise 6.1

167

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

the

Patient's

Immunization

Record

170

Viewing

and

Graphing

the Patient's Lab

Results

170

Creating

anExcuse Note 171

Changing

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

Addenda

toan

Office

Visit Note

178

B

EHR Exercise 6.7 178

6.6

Office Visit

Reports

180

Examination

Report

toPatient 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

Using

Terminology

187

Checking

Your

Understanding

187

Applying

Your

Knowledge

188

Chapter

7

Clinical Tools

189

Learning

Outcomes 189

What You

Need

to

Know

189

Key

Terms 189

Introduction

190

7.1 Chart Evaluation

190

B

EHR Exercise7.1 196

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 Exercise7.5 206

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

7Review 217

Using Terminology

217

Checking

Your

Understanding

218

Applying

Your

Knowledge

219

Chapter

8

Creating Templates

220

Learning

Outcomes 220

What

You

Need

toKnow

220

Key

Terms 220

Introduction

221

8.1

Creating

Office Visit

Templates

221

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

(6)

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

Checking

Your

Understanding

235

Applying

Your

Knowledge

236

Chapter

9

Tests,

Procedures,

and

Codes

237

Learning

Outcomes 237

What

You NeedtoKnow 237

Key

Terms

237

Introduction

238

9.1

Ordering

a

Test

238

£?

EHR Exercise 9.1 240

&

EHR Exercise

9.2

240

9.2

SpringLabs

and Reference

Lab Results

240

Access

Stored

Data 241

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

aNew Procedure 255

Creating

anIinmunization

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

aNew

Diagnosis

261

Editing

a

Diagnosis

262

ICD-10

Codes

262

5

EHR

Exercise

9.8 264

&EHRExercise9.9

265

Chapter

9

Summary

266

Chapter

9Review 267

UsingTerminology

267

Checking

Your

Understanding

267

ApplyingYour Knowledge

269

Chapter

10

Productivity

Center and

Utilities

270

Learning

Outcomes 270

What

You

Need

toKnow 270

Key

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

EDD Calculator 280

Simple

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

Checking

Your

Understanding

291

(7)

Chapter

11

Applying

Your

Knowledge

293

Learning

Outcomes 293

What You

Need

toKnow 293

Introduction

294

11.1 Practice View Screen

294

Office Schedule

294

8

EHR

Exercise 11.1 294

8

EHRExercise 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

FaceSheet 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 Exercise11.14 307

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

EHRExercise11.20 311

Office Visit

Activities 315

8

EHR

Exercise 11.21 315

8

EHR

Exercise 11.22 316

Chapter

12

EHR Practicum

317

Learning

Outcome

317

What You NeedtoKnow 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 Exercise12.22 321

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 Documentsfor

SpringCharts

Network Version 414

Glossary

424 Notes 430 Index 431

References

Related documents

When powerpoints are being used, the child will be given the access code to the Smart Learning Suite – whereby they are able to access the live powerpoints (including class

Specifically, the study found that top management commitment and stakeholder pressure positively influence sustainable environmental manufacturing practices and that

As we increase (counterfac- tually) the rate at which low-skill jobs produce new skills (leaving both the distribution of treatment e ects of schooling and the return to high-skill

In order to prepare our contribution to an Assessment Model for VSEs (see next section), we present in the left part of Figure 1, the conceptual model of the ISO/IEC 15504

PROTECTO 401 Ceramic Epoxy Lining was designed specifically for protection of Ductile Iron for sanitary sewer service by providing a reliability similar to cement mortar lining

• Cisco Software Advisor - Match Cisco IOS Software and Cisco Catalyst® O/S features to releases, and determine which software release supports a given hardware device. It

Even though Sweden may figure rather favorably after the UK in Europe in industrially competent venture capital supply, both volume and variety of that supply is deficient when

However, single-threaded software masking schemes process one share at a time, thus it is important to test it under a multivariate analysis to check if there’s any leakage due to