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Electronic Health Records
by Hamilton, ByronEdition: 3rd
Format: Spiral Bound
Pub. Date: 2012-07-24
Publisher(s): McGraw-Hill Education
List Price: $94.97
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Summary
Hamilton, Electronic Health Records, 3e is the top choice for training students using live and up-to-date SpringCharts EHR software. Electronic Health Records3e builds transferable medical documentation skills with a variety of exercises that walk students through different facets of using an EHR in the medical office. As students progress through SpringCharts, they learn to gather patient information, schedule appointments, record examination information, process lab tests, select codes, and more. Students who complete this course will learn the appropriate terminology and skills to use any EHR software program with minimal additional training. The practical, systematic approach is based on real-world medical office activities.
Table of Contents
Electronic Health Records, Third Edition
Chapter 1 The Electronic Health Record
1.1 Overview of the Electronic Health Record
The Concept
EHR Models
1.2 History of the Electronic Health Record
1.3 EHR Terminology
1.4 Government Involvement in the EHR
Medicare Improvements for Patients and Providers Act of 2008
American Recovery and Reinvestment Act of 2009
Beacon Community Program
Regional Extension Centers
1.5 Healthcare Processes and the EHR
1.6 Benefits of the EHR
Enhanced Accessibility to Clinical Information
Improved Patient Safety
Enhanced Quality of Patient Care
Greater Efficiency and Savings
1.7 Barriers to the EHR
Lack of Standards
Unknown Cost and Return on Investment
Concern about Difficulty Operating the System
Significant Changes in Clinic Processes
Lack of Trust and Safety
1.8 The Future of the Electronic Health Record
Chapter 2 Standards and Features of Electronic Health Records
2.1 History of EHR Standards
Health Insurance Portability and Accountability Act (HIPAA)
Consolidated Health Information (CHI)
Institute of Medicine (IOM)
The Certification Commission for Health Information Technology (CCHIT)
Office of the National Coordinator for Health Information Technology (ONC)
2.2 Meaningful Use (MU)
Computerized Physician Order Entry (CPOE)
2.3 Privacy and Security of the EHR
HIPAA and Privacy/Security
The Health Information Technology for Economic and Clinical Health (HITECH) Act
USA PATRIOT Act and Homeland Security
Other Privacy Concerns
2.4 EHR Implementation and Technology
2.5 Electronic Health Record Competencies
Chapter 3 Introduction and Setup
3.1 The Story of SpringCharts EHR and Its Features
Development of SpringCharts
Clinical Tools
Administrative Tools
Outside Links
Certification and Meaningful Use Criteria
3.2 User Preferences
Preferences 1
Preferences 2
Password
Signature
New Address
EHR Exercise 3.1
3.3 Address Data Setup
New Address
Editing Addresses
EHR Exercise 3.2
EHR Exercise 3.3
EHR Exercise 3.4
EHR Exercise 3.5
EHR Exercise 3.6
EHR Exercise 3.7
3.4 Patient Data Setup
New Patient
Editing Patients
EHR Exercise 3.8
EHR Exercise 3.9
EHR Exercise 3.10
3.5 Insurance Data Setup
New Insurance Company
Editing Insurance Information
EHR Exercise 3.11
EHR Exercise 3.12
Chapter 4 The Clinic Administration
4.1 The Practice View Screen
EHR Exercise 4.1
4.2 The Appointment Calendar
EHR Exercise 4.2
EHR Exercise 4.3
EHR Exercise 4.4
EHR Exercise 4.5
EHR Exercise 4.6
EHR Exercise 4.7
EHR Exercise 4.8
EHR Exercise 4.9
EHR Exercise 4.10
4.3 The Patient Tracker
Color Coding
Location and Status
Tracker Group
Patient Info
Check Out
Tracker Archive
EHR Exercise 4.11
EHR Exercise 4.12
EHR Exercise 4.13
EHR Exercise 4.14
EHR Exercise 4.15
EHR Exercise 4.16
EHR Exercise 4.17
4.4 To-Do Lists and Reminders
My To Do List
EHR Exercise 4.18
EHR Exercise 4.19
EHR Exercise 4.20
EHR Exercise 4.21
EHR Exercise 4.22
4.5 Internal Messages
Nonpatient Messages
Messages Concerning Patients
EHR Exercise 4.23
EHR Exercise 4.24
EHR Exercise 4.25
EHR Exercise 4.26
4.6 Urgent Messages and E-Mails
EHR Exercise 4.27
EHR Exercise 4.28
EHR Exercise 4.29
EHR Exercise 4.30
Chapter 5 The Patient Chart
5.1 Overview of the Patient Chart
The Face Sheet
The Care Tree
EHR Exercise 5.1
5.2 Creating a Face Sheet
Allergies
Social History
Past Medical History (PMHX)
Family Medical History (FMHX) Referrals
Chart Note
Routine Meds
Outside Meds
Problem List
Chart Alert
Patient Annotations
Patient Requests
Saving and Printing
EHR Exercise 5.2
5.3 Procedures in a Patient’s Chart
Adding the Primary Insurance
Entering Past Immunizations
Graphing Vital Signs
EHR Exercise 5.3
EHR Exercise 5.4
5.4 New Activities in a Patient’s Chart
New TC Note
New Vitals Only
New Letter to the Patient
New Letter About the Patient
New Test Report
New Excuse/Note/Order
EHR Exercise 5.5
EHR Exercise 5.6
EHR Exercise 5.7
Chapter 6 The Office Visit
6.1 Components of the Office Visit
6.2 Building an Office Visit Note
EHR Exercise 6.1
EHR Exercise 6.2
EHR Exercise 6.3
6.3 Activities within the Office Visit Screen
Editing the Patient’s Face Sheet
Modifying and Printing the Patient’s Immunization Record
Viewing and Graphing the Patient’s Lab Results
Creating an Excuse Note
Changing the Chart Tab
Report to Patient
EHR Exercise 6.4
EHR Exercise 6.5
6.4 Routing Slip
EHR Exercise 6.6
6.5 Adding Addendums to an Office Visit Note
EHR Exercise 6.7
6.6 Office Visit Reports
Report to Patient
Office Visit Note
History and Physical Report
Office Visit Template Reports
EHR Exercise 6.8
EHR Exercise 6.9
EHR Exercise 6.10
Chapter 7 Clinical Tools
7.1 Chart Evaluation
EHR Exercise 7.1
7.2 Test Orders
EHR Exercise 7.2
7.3 Evaluation & Management Coder
EHR Exercise 7.3
7.4 Superbill Form
EHR Exercise 7.4
7.5 Patient Instructions
EHR Exercise 7.5
EHR Exercise 7.6
7.6 Care Plans and Practice Guidelines
EHR Exercise 7.7
7.7 Drawing Program
7.8 Importing Documents
EHR Exercise 7.8
Chapter 8 Creating Templates
8.1 Creating Office Visit Templates
EHR Exercise 8.1
EHR Exercise 8.2
8.2 Creating Physician Order Templates
EHR Exercise 8.3
8.3 Creating Letter Templates
EHR Exercise 8.4
8.4 Template Manager
EHR Exercise 8.5
8.5 Creating Procedure Templates
EHR Exercise 8.6
Chapter 9 Tests, Procedures, and Codes
9.1 Ordering a Test
EHR Exercise 9.1
EHR Exercise 9.2
9.2 SpringLabs and Reference Lab Results
Access Stored Data
Manage Test Name Synonyms
Matching
Force Entering
EHR Exercise 9.3
9.3 Processing and Charting Tests
EHR Exercise 9.4
EHR Exercise 9.5
9.4 Creating a Test Report
EHR Exercise 9.6
9.5 Documenting, Activating, and Editing Procedure Codes
Documenting a Procedure
Creating a New Procedure
Creating an Immunization Procedure
Editing a Procedure
EHR Exercise 9.7
9.6 Documenting, Activating, and Editing Diagnosis Codes
Documenting a Diagnosis
Creating a New Diagnosis
EHR Exercise 9.8
Chapter 10 Productivity Center and Utilities
10.1 Bulletin Board
EHR Exercise 10.1
10.2 Integrated Faxing
Outbound Fax History
Inbound Fax List
Conversion Calculator
EHR Exercise 10.2
10.3 Time Clock
EHR Exercise 10.3
10.4 My Websites
EHR Exercise 10.4
10.5 Calculators
Conversion Calculator
Pregnancy EDD Calculator
Simple Calculator
EHR Exercise 10.5
10.6 Patient Database Reporting
Form Letters
Reports
EHR Exercise 10.6
10.7 Patient Archives
EHR Exercise 10.7
Chapter 11 Applying Your Knowledge
11.1 Practice View Screen
Office Schedule
EHR Exercise 11.1
EHR Exercise 11.2
Patient Tracker
EHR Exercise 11.3
EHR Exercise 11.4
EHR Exercise 11.5
To Do List
EHR Exercise 11.6
EHR Exercise 11.7
Messages
EHR Exercise 11.8
EHR Exercise 11.9
EHR Exercise 11.10
11.2 Patient Chart Screen
Face Sheet
EHR Exercise 11.11
Patient Chart Activities
EHR Exercise 11.12
EHR Exercise 11.13
EHR Exercise 11.14
EHR Exercise 11.15
EHR Exercise 11.16
EHR Exercise 11.17
EHR Exercise 11.18
11.3 Office Visit Screen
Office Visit Note
EHR Exercise 11.19
EHR Exercise 11.20
Office Visit Activities
EHR Exercise 11.21
EHR Exercise 11.22
Chapter 12 EHR Practicum
12.1 Recording Information from Paper Source Documents
EHR Exercise 12.1
EHR Exercise 12.2
EHR Exercise 12.3
EHR Exercise 12.4
EHR Exercise 12.5
EHR Exercise 12.6
EHR Exercise 12.7
EHR Exercise 12.8
EHR Exercise 12.9
EHR Exercise 12.10
EHR Exercise 12.11
EHR Exercise 12.12
EHR Exercise 12.13
EHR Exercise 12.14
EHR Exercise 12.15
EHR Exercise 12.16
EHR Exercise 12.17
EHR Exercise 12.18
EHR Exercise 12.19
EHR Exercise 12.20
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