9780131960794

Electronic Health Records, a foundational course in Health Information Management or Health Information Technology programs is the next "big thing" in medical technology. It coordinates exam notes, the diagnosis, the insurance billing and coding, and any procedures for each patient's medical records. Gartee's, first of its kind, "how to" text is designed to train future users of EHR programs. It is written for the clerk, the Medical Records Technician, the general administrative Medical Assistant, the Medical Biller, the Insurance Coordinator and others in the operational level. It contains screen shots, exercises and activities to help students learn how an Electronic Health Records system works and how it serves as a "coordinator" of the different facets of patient medical administration. Gartee differs from all other publications, in that they discuss EHR's as they relate only to managers, planners, and top administrators in Hospitals.

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.

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
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
Wherersquo;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
Summary
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
Summary
Learning Medical Record Software
Introducing The Medcin Student Edition
Understanding The Software
Hands On
Starting Up The Medcin Software
Navigating The Screen Hands On
Exiting And Re-Starting The software Hands On
Using The Menu to Select A Patient Hands On
Navigating The Medcin Findings Hands On
Tabs On The Medcin Nomenclature Panel
Data Entry Of The Examination Note Hands On
Creating An Encounter Hands On
Recording Subjective Findings Hands On
Removing Findings Hands On
Recording More Specific Findings Hands On
Recording History Findings
Adding Details To The Findings Hands On
Recording A Value
Using Free Text Hands On
Adding Free-text Hands On
Recording Objective Findings Hands On
Setting The Result Field Hands On
Adding Detail To Recorded Findings Hands On
Adding Episode Detail To Findings Hands On
Recording The Assessment Hands On
Recording Treatment Plan And Physician Orders
Introduction To Using Forms Hands On
Recording The Chief Comp
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Electronic Health Records Understanding and Using Computerized Medical Records

Electronic Health Records Understanding and Using Computerized Medical Records

0131960792

Summary

Author Biography

Table of Contents

Supplemental Materials