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Electronic Health Records-text Only (07 - Old Edition)


Electronic Health Records-text Only (07 - Old Edition) Cover


About the Author

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

Table of Contents Preface


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

AcknowledgementsChapter 1 Electronic Health Records - An Overview

What Are Electronic Health Records?

Why Electronic Health Records Are Important

Health Maintenance

Trend Analysis


Decision Support

Forces Driving The EHR

Where’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




Medical Devices

Chapter One Summary

 Chapter 2 Coding Standards

The Value of Codified Electronic Health Records

Forms of EHR Data

Limitations of Types of Data

Comparison of Lab Results


Health Maintenance

Standard Coding Systems

Government Influence On Coding Standards

Comparison of Prominent EHR Code Sets

How EHR Nomenclatures Differ From Other Code Sets





Nursing Code Sets

A Nurses Notes — A Real Life Story

How EHR Code Sets Differ From Billing Code Sets.





NDC And Other Drug Codes


Chapter Two Summary

 Chapter 3 Learning Medical Record Software

Introducing The Medcin Student Edition

Understanding The Software

Hands On Exercise 1: Starting Up The Medcin Software

Navigating The Screen

Hands On Exercise 2: Exiting And Re-Starting The software

Hands On Exercise 3: Using The Menu to Select A Patient

Hands On Exercise 4: Navigating The Medcin Findings

Hands On Exercise 5: Tabs On The Medcin Nomenclature Panel

Data Entry Of The Examination Note

Hands On Exercise 6: Creating An Encounter

Hands On Exercise 7: Recording Subjective Findings

Hands On Exercise 8: Removing Findings

Hands On Exercise 9: Recording More Specific Findings

Hands On Exercise 10: Recording History Findings

Adding Details To The Findings

Hands On Exercise 11: Recording A Value

Using Free Text

Hands On Exercise 12: Adding Free-text

Hands On Exercise 13: Recording Objective Findings

Hands On Exercise 14: Setting The Result Field

Hands On Exercise 15: Adding Detail To Recorded Findings

Hands On Exercise 16: Adding Episode Detail To Findings

Hands On Exercise 17: Recording The Assessment

Hands On Exercise 18: Recording Treatment Plan And Physician Orders

Introduction To Using Forms

Hands On Exercise 19: Recording The Chief Complaint

Hands On Exercise 20: Recording Vital Signs

Paperless In Less Than A Day — A Real Life Story

Applying Your Knowledge

Hands On Exercise 21: Documenting A Visit For Headaches

Hands On Exercise 22: Printing The Narrative Report

Chapter Three SummaryChapter 4 Data Entry At The Point Of Care

Increased Familiarity With The Software

Documenting A Brief Patient Visit

Hands On Exercise 23: Documenting A Visit For A Common Cold

Why Speed of Entry Is Important In The EHR

Methods To Increase Speed of Entry

Encounter Tab Toolbar

Search and Prompt Features

How Search Works

            Hands On Exercise 24: Using Search

            Hands On Exercise 25: Ordering Diagnostic Tests

Shortcuts That Increase Speed For Routine Exams

The Concept of Lists

Hands On Exercise 26: Using Adult URI List

Hands On Exercise 27: Writing Prescriptions In An EHR

Hands On Exercise 28: Timed Experiment For Extra Credit

The Concept Of Forms

Standard Initial Visit Intake For Adult

Hands On Exercise 29: Using Forms

How I Learned To Stop Worrying And Love Forms — A Real Life Story

Chapter Four SummaryChapter 5 Electronic Coding From Medical Records

CPT-4 and ICD-9CM Codes For Billing

Understanding Evaluation And Management Codes

Using EHR Software to Calculate The Correct E&M Code

Hands On Exercise 30: Calculating E&M Code From An Exam

How The Level of An E&M Code Is Determined

Key Component: History

How History May Be Documented

Key Component: Examination

Key Component: Medical Decision Making

Determining The Level of Medical Decision Making

Other Components: Counseling, Coordination of Care, And Time

Putting It All Together

            Evaluating Key Components

Factors That Affect The E&M Code Set

Hands On Exercise 31: Exploring The E&M Calculator

Factors That Increase The Level of Codes

Fraud And Abuse

Hands On Exercise 32: Calculating E&M For A More Complex Visit

Hands On Exercise 33: Counseling More Than 50% Of Face-to-Face Time

A New Level Of Efficiency In Addition To Improved E&M Coding — A Real Life Story

ICD-9CM Codes Justify Billing

Determine The Level of Specificity

Multiple Diagnosis Codes Per Visit

Primary And Secondary Diagnoses

Medical Necessity

Ordering Tests to Confirm or Rule Out Diagnosis

How The ICD-9 Code Influences Orders And Treatment

            Hands On Exercise 34: Orders Based On Diagnosis

Hands On Exercise 35: Multiple Diagnoses

Chapter Five Summary


Comprehensive Evaluation of Chapters 1-5

Hands On Exercise 36: Examination of A Patient With AsthmaChapter 6 Advanced Techniques Speed Data Entry

Important Information About The Student Edition Patient History Program

Improved Data Entry

Management of Patients’ Health

Understanding Problem Lists

Hands On Exercise 37: Exploring Patient Management

Citing Previous Visits From Problem Lists

Hands On Exercises 38: Following Up On A Problem

EHR Data From External Sources

Vitals Signs

Diagnostic Tests

Electronic Lab Orders and results

Work Flow of Electronic Lab Orders And Results

            Hands On Exercise 39: Viewing Pending Orders and Lab Results

Graphing Lab Results From The Chart

Hands On Exercise 40: Graphing Lab Results

Quick Access To Frequent Orders

Patient Entry of Symptoms and Previous History


The Clinicians’ Dilemma

Triage by Computer

Workflow Using Patient Entered Data

Alternative Workflow

Improved Patient Information

Preventive Health Screening

Systems Integration For Better Patient Care

The First Patient Whose Life Was Saved By Expert System Software He Operated Himself — A Real Life Story

Chapter Six SummaryChapter 7 Using The EHR to Improve Patient Care

Disease Management and Prevention

Flow Sheets

Hands On Exercise 41: Working With A Flow Sheet

About The Flow Sheet View

Hands On Exercise 42: Creating A Problem Oriented Flow Sheet

Patient Involvement In Their Own Health Care

Hands on Exercise 43: Graphing Vital Signs In The Chart

Patient Entered Data Graphs

Prevention and Early Detection

Pediatric Wellness Visit

            Hands On Exercise 44: A Well-Baby Check Up

The Relation Between Vitals and Growth Charts

What is a Percentile?

Body Mass Index

            Optional Exercise 45: Calculate Your Own BMI

The Importance of Childhood Immunizations

Hands On Exercise 46: Immunizations

Immunization Schedules From The CDC

Optional Exercise 47: Determine Your Adult Immunizations

Preventative Care Screening

Quality Care For Pediatric And Adult Patients - A Real Life Story

Using EHR Data For Alerts

Reactions to Drugs or Other Treatments

Other Types of Alerts

Chapter Seven Summary

 Chapter 8 Privacy and Security of Health Records

Understanding HIPAA

HIPAA Transactions And Code Sets

HIPAA Uniform Identifiers

HIPAA Privacy Rule

Privacy Policy



Government Agencies

Minimum Necessary

A Patient’s Right To Know About Disclosures

Patient Access To Medical Records

Indirect Disclosures

Personal Representatives

Minor Children

Summary of Patient Privacy Rights

Business Associates

Civil And Criminal Penalties

The First HIPAA Privacy Case — A Real Life Story

HIPAA Security Rule

Why Security?

Privacy Rule And Security Rule Compared

Security Standards

Implementation Specifications

Administrative Safeguards

Security Management Process

Assigned Security Responsibility

Workforce Security

Information Access Management

Security Awareness And Training

Security Incident Procedures

Contingency Plan


Business Associate Contracts And Other Arrangements

Physical Safeguards

Facility Access Controls

Workstation Use

Workstation Security

Device And Media Controls

Technical Safeguards

Access Control

Audit Controls


Person Or Entity Authentication

Transmission Security

Organizational, Policies and Procedures and Documentation Requirements

Organizational Requirements

Policies And Procedures


Electronic Signatures For Medical Records

What Is An Electronic Signature And What Is Not

How Digital Signatures Work

Some An Electronic Signatures Are Not Truly Signatures

The Future Of Electronic Signatures

HIPAA Privacy, Security, And You

Hands On Exercise 48: Medical Office Privacy Policy

Chapter Eight Summary

 Chapter 9 EHR And Technology

How Technology Impacts Implementation of EHR

Style of Practice

Physical Clinic And Clinician Mobility

EHR On Computer Workstations

EHR On Laptop Computers

EHR On A Tablet PC

EHR On Handheld PDA Devices

How Wireless Networks Work

EHR Devices And The Patient

Remote EHR Access For The Provider

Enhancing Process Efficiency Through Remote Access — A Real Life Story

Speech Recognition

How Speech Recognition Software Works

Including Annotated Drawings In EHR

            Hands On Exercise 49: Annotated Dermatology Exam

Internet And The EHR

Decision Support

Provider-to-Patient E-Mail Communication

Secure Messaging


Workflow of An E-Visit

Patient Access to Electronic Health Records

            Optional Exercise 50: Creating Your Own Health Record

Chapter Nine Summary


Comprehensive Evaluation of Chapters 6-9

Hands On Exercise 51: Examination of A Patient With Arterial Disease

 Appendix A - CMS Documentation Guideline Tables

General Multi-system Examination

ENT Examination Appendix B - Information About The Student Edition History Program

Instructions for Starting History Program Software

Stopping The History Program

Indications That The History Program Is Not Running



Product Details

Understanding and Using Computerized Medical Records
Gartee, Richard
Gartee, Richard W.
Prentice Hall
Data processing
Practice Management & Reimbursement
Medical History & Records
Medical records
Allied Health Services - General
Medical records -- Data processing.
Medical Records Systems, Computerized.
Edition Description:
Trade paper
Publication Date:
April 2006
Grade Level:
College/higher education:
10.78x8.46x.80 in. 2.40 lbs.

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