This practical, hands-on book introduces you to the electronic health record (EHR) and shows you how to become proficient in using EHR software on the job. You will gain a thorough understanding of both the terminology of EHR systems and the practical use of such systems in a health care provider office setting. Some of the topics discussed include problem lists, assessments, prescription/medication management, exam notes, and diagnostic orders and results. The MedWare Chart EHR software and activities are similar to what will be encountered in the workplace.
Shirley Eichenwald Maki, MBA, RHIA, FAHIMA is Assistant Professor in the Department of Health Care Informatics and Information Management at The College of St. Scholastica, Duluth, MN.
Bonnie Petterson, PhD, RHIA is a Health Information Consultant, and the former Health Information Management Program Director at Phoenix College, which is part of the Maricopa Community Colleges in Phoenix, AZ.
Chapter 1: Electronic Health Records - An Overview Chapter 2: The EHR Framework in the Healthcare Provider Office Chapter 3: EHR Content in the Healthcare Provider Office Chapter 4: Associated Functional and Operational Content Chapter 5: Patient Scheduling, Registration and Identify Management Chapter 6: Creation and Maintenance of Problem and Allergy Lists Chapter 7: The Examination Notes, including Special Assessments Chapter 8: Treatment Plan and Treatment/Procedure Notes Chapter 9: Diagnostic test orders and results (laboratory, radiology, etc) Chapter 10: Medication orders and administration record Chapter 11: Graphic/charts (vitals, growth, immunization, etc) Chapter 12: Patient visit management Chapter 13: Patient communications Chapter 14: Diagnostic and Procedure coding and billing Chapter 15: Clinical trials Chapter 16: Continuing Care and Personal Health Records