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• Title:Electronic health records : understanding and using computerized medical records / Richard Gartee.
  
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• Author/Creator:Gartee, Richard, author.
  
• Published/Created:NY, NY : Pearson, [2016]
  ©2016
  

• Holdings

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  • Location:WOODWARD LIBRARY stacksWhere is this?
    
  • Call Number: WX175 .G244e 2016
    
  • Number of Items:1
    
  • Status:Available
    

   
• Library of Congress Subjects: Medical records--Data processing.
  
• Medical Subjects:Electronic Health Records.
  Forms and Records Control--methods.
  
• Edition:Third edition.
  
• Description:xxiii, 561 pages : color illustrations ; 28 cm
  
• Summary:"A complete, "learn by doing" approach to learning electronic health records Designed to prepare an educated clinical workforce, Electronic Health Records: Understanding and Using Computerized Medical Records is the complete "learn by doing" text and software package for everyone who must use an electronic health records (EHR) system, including doctors, nurses, medical assistants, physician assistants, and other medical office staff. It provides a thorough understanding of EHR tasks and functional benefits that is continuously reinforced by actual EHR experiences. Updated to reflect the latest EHR rules, regulations, and innovations, this new edition contains even more hands-on exercises that use real EHR software to transform theoretical EHR concepts into practical understanding."--Publisher's website.
  
• Notes:Includes bibliographical references and index.
  
• ISBN:9780134257501
  0134257502
  
• Contents:Machine generated contents note: ch. 1 History and Evolution of Electronic Health Records
  History of Electronic Health Records
  Institute of Medicine (IOM)
  Computer-based Patient Record Institute (CPRI)
  Health Insurance Portability and Accountability Act (HIPAA)
  EHR Defined
  Social Forces Driving EHR Adoption
  Health Safety
  Health Costs
  Changing Society
  Group Discussion Topic: EHR News
  Forces Driving EHR Evolution
  Office of National Coordinator for Health Information Technology
  Strategic Framework
  Federal Health IT Strategic Plan
  HITECH Act
  Strategic Plan Updates
  Meaningful Use of a Certified EHR
  Certified EHR
  Meaningful Use and Clinical Quality Measures
  EHR Adoption After HITECH
  Why Interoperability Is Important
  Group Discussion Topic: When the Chart Is Lacking
  Documenting at the Point of Care
  Real-Life Story: Where's My Chart?
  Flow of Clinical Information into the Chart
  Workflow of an Office Using Paper Charts
  Workflow of an Office Fully Using an EHR
  Group Discussion About Workflow
  Inpatient Charts versus Outpatient Charts
  Patient Registration and Appointment Scheduling
  Patient Administration
  Tutorial Exercise 1A Overview of a Patient Administration Module
  Patient and Provider Scheduling
  Tutorial Exercise 1B Overview of a Scheduling Module
  ch. One Summary
  ch. 2 Functional EHR Systems
  Format of Data Determines Potential Benefits
  EHR Data Formats
  Limitations of Certain Types of Data
  Standard EHR Coding Systems
  Prominent EHR Code Sets
  SNOMED-CT
  SNOMED-CT Structure
  Medcin
  Medcin Structure
  LOINC
  Clinical Care Classification System (CCC)
  RxNorm
  UMLS
  How EHR Code Sets Differ From Code Sets Used for Billing
  ICD-10CM
  CPT-4®
  Code Usage
  Exchanging Data with Other Standard Code Sets
  Capturing and Recording EHR Data
  Importing Digital Images
  Guided Exercise 2A Exploring a Document Imaging System
  Cataloging Digital Images
  Guided Exercise 2B Importing and Cataloging Images
  Picture Archival and Communication System (PAC)
  Importing Text to the EHR
  Importing Coded EHR Data
  Patient-Entered Data
  Provider-Entered Data
  Health Information Exchange
  HL7
  DICOM
  CDISC
  Biomedical Devices
  Telemonitors
  Real-Life Story: Enhancing Process Efficiency through Remote Access
  Functional Benefits from Codified Records
  Trend Analysis
  Critical Thinking Exercise 2C: Retrieving a Scanned Lab Report
  Lab Report as Digital Image
  Lab Report as Text Data
  Coded Lab Data
  Alerts
  Drug Utilization Review
  Formulary Alerts
  Other Types of Alerts
  Health Maintenance
  Preventive Care
  Immunizations
  Decision Support
  Meeting the IOM Definition of an EHR
  ch. Two Summary
  ch. 3 Learning Medical Record Software
  Introducing the Quippe® Student Edition Software
  About the Exercises in This Book
  Creating Your First Patient Encounter Note
  Guided Exercise 3A Understanding the Software
  Understanding the Toolbar
  Navigating Medcin Content
  Guided Exercise 3B Adding Clinical Concepts to the Workspace
  Using a More Specific Finding
  Guided Exercise 3C Patient with Caffeine Withdrawal Headache
  Adding Details to the Findings
  Guided Exercise 3D Using the Details Pop-up Window
  Chief Complaint and Vital Signs
  Guided Exercise 3E Recording Chief Complaint and Vital Signs
  Critical Thinking Exercise 3F Patient Suffering Withdrawal Headaches
  Real-Life Story: Paperless in Less Than a Day
  ch. Three Summary
  Testing Your Skill Exercise 3G: Another Cause of Headache
  ch. 4 Increased Familiarity with EHR Software
  Applying Your Knowledge
  Documenting a Brief Patient Visit
  Guided Exercise 4A Documenting a Visit for Common Cold
  Visually Different EHR Styles
  Real-Life Story: A Nurse's Notes
  Guided Exercise 4B Recording Findings Using Alternate Methods
  Encounter Notes Without Yes/No Check Boxes
  Additional Exercises
  Critical Thinking Exercise 4C Patient with Sinusitis
  Critical Thinking Exercise 4D Patient with Urinary Problem
  ch. Four Summary
  Testing Your Skill Exercise 4E Asthma Patient Who Sleeps with a Dog
  ch. 5 Data Entry at the Point of Care
  Why Speed of Entry Is Important in the EHR
  Templates, Lists, and Forms Speed Data Entry
  Shortcuts That Speed Documentation of Typical Cases
  Concept of Templates
  Concept of Lists
  Guided Exercise 5A Using an Adult URI List
  Review of Systems and Pertinent Negatives
  Guided Exercise 5B Using Lists and Otherwise Normal
  Critical Thinking Exercise 5C Using Syncope List for a TIA Case
  Concept of Forms
  Comparison of Lists and Forms
  Initial Intake Form for an Adult
  Guided Exercise 5D Using Forms
  Customized Forms
  Real-Life Story: How I Learned to Stop Worrying and Love Forms
  Critical Thinking Exercise 5E Using a Form and a List
  ch. Five Summary
  Testing Your Skill Exercise 5F Patient with Dyspnea
  ch. 6 Understanding Electronic Orders
  Importance of Electronic Orders and Results
  Recording Orders in the Student Edition
  Learning to Use the Search and Prompt Features
  How Search Works
  Guided Exercise 6A Using Search and Prompt, and Ordering Tests
  Moving Concepts and Findings to a Different Section
  Merge Prompt
  -Intelligent Prompting
  Lab Orders and Reports
  Workflow of Electronic Lab Orders and Results
  Guided Exercise 6B Ordering an X-Ray
  Radiology Orders and Reports
  Workflow of Radiology Orders
  Critical Thinking Exercise 6C Ordering Tests and an X-Ray
  Protocols Based on Diagnosis
  Primary and Secondary Diagnoses
  Multiple Diagnoses
  Rule-Out Diagnosis
  Using Symptoms and History to Prompt for Findings
  Guided Exercise 6D Patient With Multiple Diagnoses
  Medication Orders
  Electronic Prescriptions
  Closing the Loop on Safe Medication Administration
  Guided Exercise 6E Writing Prescriptions in an EHR
  Quick Access to Frequent Orders
  Guided Exercise 6F Ordering Medications Using Discharge Orders
  Real-Life Story: When Orders and Results Are Critical
  ch. Six Summary
  Testing Your Skill Exercise 6G Discharging a Patient with Deep Vein Thrombosis
  Comprehensive Evaluation of Chapters 1
  6
  pt. I Testing Your Knowledge of Chapters 1
  6
  pt. II Guided Exercise CE1: Document Image Retrieval
  pt. III Critical Thinking Exercise CE2: ER Visit for Shortness of Breath
  ch. 7 Problem Lists, Lab Results, and Body Mass Index
  Longitudinal Patient Records to Manage Patients' Health
  Understanding Problem Lists
  Problem-oriented Chart
  Guided Exercise 7A Working With a Problem-oriented Chart
  Citing Previous Encounter Data
  Guided Exercise 7B Adding Problems, Retrieving and Citing Lab Results
  Orders and Results Management
  Guided Exercise 7C Retrieving Pending Lab Results
  Critical Thinking Exercise 7D Using Lab Results to Rule Out Lead Poisoning
  Body Mass Index
  Real-Life Story: Experiencing the Functional Benefits of an EHR
  Waist Circumference and BMI
  Critical Thinking Exercise 7E Determining BMI Category for a Patient
  Guided Exercise 7F Calculating BMI and Trending Weight for a Diabetic Patient
  Critical Thinking Exercise 7G Discovering Your BMI and Category
  ch. Seven Summary
  Testing Your Skill Exercise 7H Patient with Upper Abdominal Chest Pain
  ch. 8 Flow Sheets, Annotated Drawings, and Graphs
  Learning to Use Flow Sheets
  Guided Exercise 8A Working with a Flow Sheet
  About the Flow Sheet View
  Guided Exercise 8B Obstetric Patient's Flow Sheet
  Critical Thinking Exercise 8C Flow Sheet with Multiple Diagnoses
  Use of Anatomical Drawings in the EHR
  Navigation by Body System
  Annotated Drawings as EHR Data
  Guided Exercise 8D Annotated Dermatology Exam
  Critical Thinking Exercise 8E Examination of a Patient with Pressure Sores
  Real-Life Story: First Patient Whose Life Was Saved by Expert System Software He Operated Himself
  Using Graphs to View Trends
  Visual Aids to Engage Patients in Their Own Healthcare
  Guided Exercise 8F Trending with a Graph and Flow Sheet
  Critical Thinking Exercise 8G Graphing Weight and BMI
  ch. Eight Summary
  Testing Your Skill Exercise 8H Diabetic with High Blood Pressure
  ch. 9 Using the EHR to Improve Patient Health
  Prevention and Early Detection
  Pediatric Wellness Visits
  Guided Exercise 9A Well-Baby Checkup
  Understanding Growth Charts
  What Is a Percentile?
  CDC Growth Charts
  Guided Exercise 9B Pediatric Vitals and Growth Charts
  Importance of Childhood Immunizations
  Guided Exercise 9C Reviewing and Ordering Vaccines
  Critical Thinking Exercise 9D Determine Your Adult Immunizations
  Preventative Care Screening
  Clinical Quality Measures
  Real-Life Story: Quality Care for Pediatric and Adult Patients
  Guided Exercise 9E Applying Quality Measures to Patient Care
  About the Quality Measures Review
  Critical Thinking Exercise 9F Clinical Quality Measures for a Female Patient
  Patient-Centered Medical Home
  ch. Nine Summary
  Testing Your Skill Exercise 9G Baby's First Checkup
  ch. 10 Decision Support and Patient Involvement
  Enriching the EHR Through Connectivity
  Decision Support
  Integrated Decision Support
  Contents note continued: Guided Exercise 10A Patient with Dengue Fever
  Critical Thinking Exercise 10B Accidental Exposure to Paraquat
  Patient involvement in Their Own Healthcare
  Patient Education Material
  Guided Exercise 10C Patient Education About Risk of COPD
  Critical Thinking Exercise 10D Patient Education About Diabetes
  Using the Internet
  Critical Thinking Exercise 10E Internet Medical Research
  Secure Internet Data
  Remote EHR Access for the Provider
  Practicing Medicine Online
  Asynchronous Telemedicine at Mayo Clinic
  Teleradiology
  Telemedicine in Nursing
  Telemedicine via E-Visits
  Patient Entry of Symptoms and History
  Workflow Using Patient-Entered Data
  Internet Workflow
  Improved Patient Information
  Guided Exercise 10F Experiencing Patient-Entered HPI
  Guided Exercise 10G Reviewing Patient-Entered Data
  E-Visits
  Real-Life Story: Using the Internet to Build a Patient-Centered Practice
  Mayo Clinic Study of E-visits
  E-Visits in Practice
  Workflow of an E-Visit
  Guided Exercise 10H Patient Requests an E-Visit
  Critical Thinking Exercise 10J Clinician Completes the E-Visit
  Patient Access to Electronic Health Records
  ch. Ten Summary
  Testing Your Skills Exercise 10K Patient with Hepatitis A
  ch. 11 Privacy and Security of Health Records
  Understanding HIPAA
  Administrative Simplification Subsection
  HIPAA Transactions and Code Sets
  HIPAA Transactions
  Standard Code Sets
  HIPAA Uniform Identifiers
  HIPAA Privacy Rule
  Privacy Policy
  Consent
  Modifying HIPAA Consent
  Critical Thinking Exercise 11A Creating a Privacy Policy
  Authorization
  Research
  Research Exceptions
  Marketing
  Guided Exercise 11B Authorization for Release of PHI
  Government Agencies
  Minimum Necessary
  Incidental Disclosures
  Patient's Right to Know About Disclosures
  Patient Access to Medical Records
  Personal Representatives
  Minor Children
  Critical Thinking Exercise 11C What Is Required?
  Business Associates
  Electronic Health Information Exchange
  Real-Life Story: The First HIPAA Privacy Case
  Civil and Criminal Penalties
  HIPAA Security Rule
  Why a Security Rule?
  Privacy Rule and Security Rule Compared
  Critical Thinking Exercise 11D Comparing Privacy and Security Rules
  Security Standards
  Implementation Specifications
  Administrative Safeguards20
  Security Management Process
  Critical Thinking Exercise 11E How to Assess Security Risk
  Assigned Security Responsibility
  Workforce Security
  Information Access Management
  Security Awareness and Training
  Security Incident Procedures
  Contingency Plan
  Evaluation
  Critical Thinking Exercise 11F Developing a Contingency Plan
  Real-Life Story: Contingency Plans Ensure Continued Ability to Deliver Care
  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
  Integrity
  Person or Entity Authentication
  Transmission Security
  Organizational, Policies and Procedures, and Documentation Requirements
  Organizational Requirements
  Policies and Procedures
  Documentation
  Minimizing the Risk of Mobile Devices
  Critical Thinking Exercise 11G Securing EHR Access
  Breach Notification Requirements24
  Individual Notice
  Media Notice
  Notice to the Secretary
  Notification by a Business Associate
  Electronic Signatures for Health Records
  HIPAA Privacy, Security, and You
  ch. Eleven Summary
  ch. 12 EHR Coding and Reimbursement
  EHR and Reimbursement
  HIPAA-Required Code Sets
  Diagnoses Codes Justify Billing
  Primary and Secondary Diagnoses
  Multiple Diagnoses
  Guided Exercise 12A Using Code Review
  CPT-4 and HCPCS Codes
  Evaluation and Management (E&M) Codes
  Four Levels of E&M Codes
  How the Level of an E&M Code Is Determined
  Undercoding
  Accurate Coding
  Using EHR Software to Understand E&M Codes
  Guided Exercise 12B Calculating the E&M Code from an Encounter
  Key Components
  Levels of Key Components
  Key Component: History
  Key Component: Examination
  Guided Exercise 12C Understanding the Examination Component
  Levels of Key Component: Examination
  Key Component: Medical Decision Making
  Guided Exercise 12D Understanding the MDM Component
  Determining the Level of Medical Decision Making
  Other Components: Counseling, Coordination of Care, and Time
  Putting It All Together
  Evaluating Key Components
  How Changes in Key Components Affect the E&M Code
  Guided Exercise 12E Calculating E&M for a More Complex Visit
  Guided Exercise 12F Counseling Over 50 Percent of Face-to-Face Time
  Critical Thinking Exercise 12G Understanding How Procedures Are Posted to the Billing System
  Real-Life Story: A New Level of Efficiency in Addition to Improved E&M Coding
  Factors That Affect the E&M Code Set
  Guided Exercise 12H Exploring Other Factors of E&M Codes
  Clinical Setting
  Detailed Service Type
  Exam Type
  ch. Twelve Summary
  Testing Your Skill Exercise 12J Counseling an Established Patient
  Comprehensive Evaluation of Chapters 7
  12
  pt. I Testing Your Knowledge of Chapters 7
  12
  pt. II Critical Thinking Exercise CE3: Examination of a Patient with Arterial Disease
  pt. III Critical Thinking Exercise CE4: Counseling and Education for a Patient with Arterial Disease
  pt. IV Testing Your Skill Exercise CE5: Patient Signs HIPAA Authorization.