Electronic
Health Records
third edition
Byron
R. Hamilton
CEO,
Med-Soft National
Training
Institution—Colorado, BA,
MA
Mc
Graw
Hill
Connect
\
Learntable
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
xvBook Reviews xv
Technical
Edit/Accuracy
Panel xviDigital Resources xvi
Acknowledgments
from the Author xviWALKTHROUGH xviii
ACOMMITMENTTO ACCURACY xx
Chapter
1
The Electronic Health
Record
1
Learning
Outcomes 1What
YouNeed
toKnow 1Key
Terms
1Introduction
2
1.1 Overview
of the Electronic
Health
Record
2
The
Concept
2EHR 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 9American
Recovery
and Reinvestment Actof 2009 9
Beacon
Community Program
11Regional
Extension Centers 111.5 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
1Summary
23Chapter
1Review 25UsingTerminology
25Checking
YourUnderstanding
25ApplyingYour
Knowledge
27Chapter
2
Standards and Features of
Electronic
Health Records
28
Learning
Outcomes
28WhatYouNeedtoKnow 28
Key
Terms 28Introduction
29
2.1
History
of EHR
Standards
29
Health Insurance
Portability
and
Accountability
Act(HTPAA)
29Consolidated
Health Information(CHI)
29Instituteof Medicine
(IOM)
30The Certification Commission for
Health
Information
Technology (CCHTT)
31Office of the National
Coordinator
forHealthInformation
Technology (ONC)
322.2 EHR
Functionality
33
Meaningful
Use(MU)
33Computerized
ProviderOrder
Entry
(CPOE)
392.3
Privacy
and
Security
of
the EHR
40
USA
PATRIOT
Actand HomelandSecurity
40HTPAA and
Privacy/Security
41The Health Information
Technology
for Economic and
Clinical Health
(HITECH)
Act 42Other
Privacy
Concerns 432.4 EHR
Implementation
and
2.5
Electronic
Health Record
Competencies
45
Chapter
2Summary
47Chapter
2Review 49Using
Terminology
49Checking
YourUnderstanding
49Applying
YourKnowledge
51Chapter
3
Introduction
and
Setup
54
Learning
Outcomes 54What
YouNeed
toKnow
54
Key
Terms 54Introduction
55
3.1 The
Story
of
SpringCharts
EHR
Software
and
Its
Features
55
Development
of
SpringCharts
55 ClinicalTools
57Administrative
Took
57Certification
andMeaningful
UseCriteria
57Privacy
andSecurity
593.2 User
Preferences
60
Preferences!
60Preferences 2 63
Password
64Signature
643
EHR Exercise3.1
65
3.3 Address Data
Setup
66
New
Address
66Editing
Addresses 68&
EHR Exercise 3.2 69&
EHR Exercise 3.369
3
EHR Exercise 3.469
& EHR
Exercise3.5
70&
EHR Exercise3.6
70&
EHRExercise 3.7
703.4 Patient Data
Setup
72
New Patient
73
Editing
Patients
753
EHR Exercise
3.8 773EHRExerci$e3.9
77&
EHR Exercise 3.10 773.5
Insurance Data
Setup
77
New
InsuranceCompany
78
Editing
InsuranceInformation
78&
EHRExercise
3.11 79&
EHRExercise
3.12 79Chapter
3Summary
80Chapter
3Review 81Using
Terminology
81Checking
YourUnderstanding
82Applying
YourKnowledge
83Chapter
4
The
Clinic Administration
84
Learning
Outcomes
84What You Need
toKnow 84 'KeyTerms
84Introduction
85
4.1
The Practice
View Screen
85
3
EHR Exercise 4.1 874.2
Appointment
Schedule
87
&
EHR Exercise 4.2 918
EHR Exercise 4.3 913
EHR Exercise 4.4 913
EHR Exercise 4.5 913
EHRExercise
4.6 923
EHRExercise
4.7 923
EHR Exercise
4.8 923
EHRExercise 4.9 924.3
Patient
Tracker
93
Color
Coding
94
Location
and Status
95Tracker
Group
96 Patient Info 96Check
out 97Tracker Archive 98
3
EHR Exercise 4.10 993
EHRExercise 4.11
99
3
EHR Exercise 4.12 993EHRExercise4.13
993
EHR
Exercise 4.14 1003
EHR Exercise 4.15
1003
EHR Exercise 4.16 1003
EHR Exercise 4.17 1003
EHR Exercise 4.18 101ff
EHR Exercise 4.20 101ff EHR Exercise
4.21 1014.4
To Do
Lists and Reminders
102
My
ToDo List 103ff
EHR Exercise 4.22 104ff
EHR Exercise 4.23 104ff
EHRExercise
4.24 104ff
EHRExercise
4.25 1054.5 Internal
Messages
105
Nonpatient Messages
105Messages Concerning
Patients
107ff
EHR Exercise 4.26 109ff
EHR Exercise 4.27109
ff
EHR Exercise 4.28 1104.6
Urgent Messages
111
ff
EHR Exercise 4.29 112ff
EHR
Exercise 4.30 112ff
EHR Exercise
4.31 112Chapter
4Summary
113Chapter
4Review 114Using Terminology
114Checking
YourUnderstanding
114Applying
YourKnowledge
116Chapter
5
The Patient Chart
117
Learning
Outcomes 117What You NeedtoKnow 117
Key
Terms 117Introduction
118
5.1 Overview of
the Patient
Chart
118
Face Sheet 120
Care
Tree 121ff
EHR Exercise 5.1 1225.2
Creating
aFace Sheet
123
Allergies
123Social
History
125Past Medical
History (PMHX)
126
Family
Medical
History
(FMHX)
127Referrals 127
Chart Note 128
Routine Medications 129
Outside
Medications 131Problem
List 131Chart Alert
133
Patient Annotations
133Patient
Requests
133Saving
andPrinting
134ff
EHRExercise 5.2 1345.3 Procedures in
aPatient's
Chart
136
Adding
thePrimary
Insurance
136Entering
Past Immunizations137
Graphing
VitalSigns
138ff
EHR Exercise 5.3 139ff
EHRExercise 5.4 1395.4
New Activities in
aPatient's
Chart
140
New TC Note 140
New Vitals
Only
141New
Lettertothe Patient 143New
Letterabout
aPatient 144New
TestReport
tothe Patient 145 NewExcuse/Note/Order
147ff
EHR Exercise5.5 148ff
EHR Exercise 5.6 148ff
EHR Exercise 5.7 149Chapter
5Summary
150Chapter
5 Review 151UsingTerminology
151Checking
YourUnderstanding
151ApplyingYour Knowledge
152Chapter
6
The Office
Visit
153
Learning
Outcomes
153
What You NeedtoKnow 153
Key
Terms 153Introduction
154
6.1
Components
of the
Office Visit
154
6.2
Building
anOffice Visit Note
1
Overview
156Chief
Complaint,
PresentIllness, Review of
Systems,
andExam
156Face Sheet 158
Vitals 158
Prescriptions
159Tests 163
Procedures 164
Other Treatment 165
Follow-up
165Signing
andDating
anOVNote 166B
EHR Exercise 6.1
167B
EHR Exercise 6.2 168B
EHR Exercise 6.3 1696.3 Activities within the
Office
Visit Screen
169
Editing
the Patient's Face Sheet 169Modifying
andPrinting
the
Patient'sImmunization
Record
170Viewing
andGraphing
the Patient's LabResults
170Creating
anExcuse Note 171Changing
the Chart Tab 172&
EHR Exercise 6.4 173B
EHR Exercise 6.5 1736.4
Routing Slip
174
&
EHR Exercise 6.6 1776.5
Adding
Addenda
toanOffice
Visit Note
178
B
EHR Exercise 6.7 1786.6
Office Visit
Reports
180
Examination
Report
toPatient 180Office Visit
(SOAP)
Note 181History
andPhysical
Report
182 Office VisitTemplate
Reports
182B
EHR Exercise 6.8 184B
EHR Exercise 6.9 185B EHR Exercise
6.10 185Chapter
6Summary
186Chapter
6 Review 187Using
Terminology
187Checking
YourUnderstanding
187Applying
YourKnowledge
188Chapter
7
Clinical Tools
189
Learning
Outcomes 189What You
Need
toKnow
189Key
Terms 189Introduction
190
7.1 Chart Evaluation
190
B
EHR Exercise7.1 1967.2
Test Orders
196
B
EHR Exercise 7.2 1987.3
Evaluation JL
Management
Coder
199
B
EHR Exercise 7.3 2007.4
Superbill
Form
201
B
EHR Exercise 7.4 2017.5 Patient Instructions
202
B
EHR Exercise7.5 206B EHR Exercise
7.6 2077.6
Care
Plans and Practice
Guidelines
207
B
EHR Exercise 7.7 2097.7
Drawing Program
209
7.8
Importing
Documents
210
B
EHR Exercise 7.8216
Chapter
7Summary
216Chapter
7Review 217Using Terminology
217Checking
YourUnderstanding
218Applying
YourKnowledge
219Chapter
8
Creating Templates
220
Learning
Outcomes 220What
YouNeed
toKnow220
Key
Terms 220Introduction
221
8.1
Creating
Office Visit
Templates
221
B
EHR Exercise 8.1 223B
EHR Exercise 8.2 2238.2
Creating
Physician
Order
Templates
224
B
EHR Exercise 8.3 2278.3
Creating
Letter
Templates
228
8.4
Template
Manager
230
&
EHR Exercise 8.5
2308.5
Creating
Procedure
Templates
231
&
EHR Exercise 8.6233
Chapter
8Summary
234Chapter
8 Review 234Using Terminology
234Checking
YourUnderstanding
235Applying
YourKnowledge
236Chapter
9
Tests,
Procedures,
and
Codes
237
Learning
Outcomes 237What
You NeedtoKnow 237Key
Terms
237Introduction
238
9.1
Ordering
aTest
238
£?
EHR Exercise 9.1 240&
EHR Exercise9.2
240
9.2
SpringLabs
and Reference
Lab Results
240
Access
Stored
Data 241Manage
Test NameSynonyms
242Matching
243Force
Entering
andDeleting
244i?
EHR Exercise 9.3 2459.3
Processing
and
Charting
Tests
246
&
EHR
Exercise 9.4 250&
EHR Exercise 9.5 2519.4
Creating
aTest
Report
252
&
EHR Exercise 9.6 2549.5
Documenting, Activating,
and
Editing
Procedure Codes
254
Documenting
aProcedure
255Creating
aNew Procedure 255Creating
anIinmunizationProcedure
257
Editing
aProcedure
258& EHR Exercise
9.7259
9.6
Documenting, Activating,
and
Editing
Diagnosis
Codes
260
Documenting
aDiagnosis
260
Creating
aNewDiagnosis
261Editing
aDiagnosis
262ICD-10
Codes
2625
EHRExercise
9.8 264&EHRExercise9.9
265Chapter
9Summary
266Chapter
9Review 267UsingTerminology
267Checking
YourUnderstanding
267ApplyingYour Knowledge
269Chapter
10
Productivity
Center and
Utilities
270
Learning
Outcomes 270What
YouNeed
toKnow 270Key
Terms 270Introduction
271
10.1 Bulletin Board
271
6
EHR Exercise 10.1 27310.2
Integrated
Faxing
273
Outbound Fax
History
274Inbound Fax List 274
iff
EHR Exercise 10.2 27510.3 Time
Clock
276
iff
EHR Exercise 10.3 27810.4
My
Websites
278
iff
EHRExercise
10.4 27910.5
Calculators
279
Conversion Calculator 280
Pregnancy
EDD Calculator 280Simple
Calculator
280S
EHRExercise
10.5 28110.6 Patient
Database
Reporting
281
Form Letters 284
Reports
284iff
EHRExercise
10.6 28610.7
Patient Archive
287
iff
EHR Exercise 10.7 288Chapter
10Summary
289Chapter
10 Review 290Using Terminology
290Checking
YourUnderstanding
291Chapter
11
Applying
Your
Knowledge
293
Learning
Outcomes 293What You
Need
toKnow 293Introduction
294
11.1 Practice View Screen
294
Office Schedule
2948
EHR
Exercise 11.1 2948
EHRExercise 11.2 296 Patient Tracker 2978
EHR Exercise 11.3 2973
EHR Exercise 11.4 2978
EHR Exercise 11.5 298To Do
List
299&
EHR Exercise 11.6 2998
EHR
Exercise 11.7300
Messages
3018
EHR Exercise 11.8 3018
EHR Exercise 11.9 3018
EHR Exercise 11.10 30111.2
Patient Chart Screen
303
FaceSheet 303
8
EHR Exercise 11.11 303Patient Chart Activities 305
8
EHR Exercise 11.12 3058
EHR Exercise 11.13 3068
EHR Exercise11.14 3078
EHR Exercise 11.15 3078
EHR Exercise
11.16 3088
EHR Exercise 11.17 3098
EHR Exercise 11.18 30911.3 Office Visit Screen
310
Office Visit Note 310
8
EHR
Exercise 11.19 3108
EHRExercise11.20 311Office Visit
Activities 3158
EHR
Exercise 11.21 3158
EHR
Exercise 11.22 316Chapter
12
EHR Practicum
317
Learning
Outcome
317What You NeedtoKnow 317
Introduction
318
12.1
Recording
Information from
Paper
Source Documents
318
8
EHR Exercise 12.1 3188
EHRExercise
12.2 3188
EHR Exercise 12.3 3188
EHR Exercise 12.4 3198
EHR Exercise 12.5 3198
EHR Exercise 12.6 3198
EHR Exercise 12.7 3198
EHR Exercise 12.8 3198
EHR Exercise 12.9 3198
EHR Exercise 12.10319
8
EHR Exercise12.11
3208 EHR Exercise
12.12 3208
EHR Exercise
12.13 3208
EHR Exercise 12.14 3208
EHR Exercise 12.15 3208
EHR Exercise 12.16 3208
EHR Exercise 12.17 3208
EHR Exercise 12.18 3218
EHR Exercise 12.19 3218
EHR Exercise 12.20 3218
EHR Exercise 12.21321
8
EHR Exercise12.22 321Appendix
A:Sample
Documents 322Appendix
B:Source Documents forSpringCharts
Single-User
Version 337Appendix
C: Exercises for the NetworkedComputer
Environment 347
Appendix
D: Source DocumentsforSpringCharts
Network Version 414