|Certificate Course in Electronic Medical Records Administration
Contact Hours: 45
|This course is approved by the Association for Healthcare Documentation Integrity (AHDI) for 10 continuing education credits (CECs), 7 Technology and the Workplace and 3 Professional Development CECs. Discounts apply for multi-employee enrollments.
The American Recovery and Reinvestment Act of 2009 has ordered that patient health records be input into computerized systems in a digital format . The transition to electronic health records is now well underway. Electronic Health Records include any information relating to the past, present or future physical /mental; health, or condition of an individual which resides in electronic system(s) used to capture, transmit, receive, store, retrieve, link and manipulate multimedia data for the primary purpose of providing health care and health-related services. It is estimated that the need for skilled persons in a variety of EHR positions will make this a demand area.
This course is organized to provide learners with a comprehensive understanding of the history, theory, and functional benefits of Electronic Health Records. Students will increase their awareness of the overall environment and function of electronic health records as well as observe its contributions to society. This course also covers the latest rules, regulations and innovations in EHR with guided exercises. These hands-on exercises use real EHR software to transform theoretical EHR concepts into practical understanding. Each chapter builds on the knowledge acquired in previous chapters. Those benefiting from this course include; Doctors, Nurses, Medical Assistants, PA’s (Physician Assistant), and other medical staff.
A student with sufficient workplace experience in the medical field and computer skills can enroll in this program without meeting the Pre-Requisite Requirements.
Anatomy and Physiology, Medical Terminology, working knowledge of computer skills, understanding of coding and reimbursement process, read instruction and apply to task, work independently.
To complete the exercises in this book, you will need access to the Medcin Student Edition software. You will need to download and install the software on a computer running the Windows operating system. Directions to download and install the software are found on the MyHealthProfessionsKit web page, which is described on the inside cover of the book. To complete the exercises in Chapters 2, 11, and both comprehensive evaluations, you will also need access to the Internet and a web browser.
Minimum Workstation Requirements:
Processor: 200 mHz Pentium
Operating system: Windows XP, Windows Vista, Window 7 (or later)
RAM: 64 megabytes (free, not counting OS)
Number of colors: 256 (8-bit color)
Display size (pixels per inch): 800 X 600 (1024 X 768 recommended)
Internet Explorer version 6 or later
You must have a mouse with at least two buttons that respectively perform the right and left click functions.
|By the end of this course, you should be able to:
1. Define electronic health records.
2. Understand the core functions of an electronic health record as defined by the Institute of Medicine.
3. Discuss social forces that are driving the adoption of electronic health records.
4. Describe federal government strategies to promote electronic health record adoption.
5. Explain why electronic health records are important.
6. Describe the flow of medical information into the chart.
7. Compare the workflow of an office using paper charts with an office using electronic health records.
8. Contrast inpatient and outpatient charts.
9. Explain why patient visits should be documented at the point of care.
|Comprehensive, end of chapter exercises are self-directed and completed by the student as they progress through the course. The course administrator reviews these and submits a grade of Pass or Fail or letter grade if needed.
|Below is an outline of the content and activities in each unit of the course.
Chapter 1: Electronic Health Records – Overview
- Evolution of Electronic Health Records
- Social Forces Driving EHR Adoption
- Government Responses
- Meaningful Use of a Certified EHR
- Why Electronic Health Records Are Important
- Flow of Clinical Information into the Chart
- Inpatient Charts versus Outpatient Charts
Chapter 2: Functional EHR Systems
- Format of Data Determines Potential Benefits
- Standard EHR Coding Systems
- Capturing and Recording EHR Data
- Functional Benefits from Codified Records
Chapter 3: Learning Medical Record Software
- Introducing the Medcin Student Edition
- Understanding the Software
- Navigating the Screen
- Data Entry of Clinical Notes
- Adding Details to the Findings
- Using Free Text
- Introduction to Using Forms
Chapter 4: Increased Familiarity with the Software
- Applying Your Knowledge
- Creating Your First Patient Encounter Note
- Documenting a Brief Patient Visit
Chapter 5: Data Entry at the Point of Care
- Why Speed of Entry Is Important in the EHR
- Lists and Forms Speed Data Entry
- Shortcuts That Speed Documentation of Typical Cases
- The Concept of Lists
- The Concept of Forms
- Initial Intake Form for an Adult
- Customized Forms
Chapter 6: Understanding Electronic Orders
- The Importance of Electronic Orders and Results
- Recording Orders in the Student Edition
- Lab Orders and Reports
- Comparison of Orders and Results Workflow
- Learning to Use the Search and Prompt Features
- Radiology Orders and Reports
- Medication Orders
- Quick Access to Frequent Orders
- Protocols Based on Diagnostic Codes
- Using Diagnosis to Find orders and Treatments
Comprehensive Evaluations of Chapters 1-6
Chapter 7: Problem Lists, Results management, and Trending
- MyHealthProfessionsKit Questions
- Hands-on Exercise
- Longitudinal Patient Records to Manage Patients’ Health
- Understanding Problem Lists
- Citing Previous Visits from Problem Lists
- Orders and Results management
- Visual Aides to Engage Patients in Their Own Healthcare
Chapter 8: Data Entry Using Flow Sheets and Anatomical Drawings
- Learning to Use Flow Sheets
- Use of Anatomical Drawings in the EHR
- Annotated Drawings as EHR Data
Chapter 9: Using the EHR to Improve Patient Health
- Prevention and Early Detection
- Pediatric Wellness Visits
- Understanding Growth Charts
- Body Mass Index
- The importance of Childhood Immunizations
- Patients’ Involvement in Their Own Healthcare
- Preventative Care Screening
Chapter 10: Privacy and Security of Health Records
- This chapter is for your review. There are no guided exercises in this chapter
Chapter 11: Using the Internet to Expedite Patient Care
- The Impact of Technology
- The Internet and the EHR
- Decisions Support Via the Web
- Understanding the Internet
- Practicing Medicine Online
- Patient Entry of Symptoms and History
- Provider-to-Patient E-Mail Communication
- Patient Access to Electronic Health Records
- The Person History Record