Integrated Electronic Health Records : A Worktext for Greenway Medical Technologies' PrimeSUITE

Chapter 1: AN OVERVIEW OF PrimeSUITE’s PRACTICE MANAGEMENT AND ELECTRONIC HEALTH RECORD SOFTWARE

1.1 Practice Management Applications

1.2 Why Adopt Electronic Health Record Applications?

1.3 Electronic Health Record Applications

1.4 The Flow of Information from Registration Through Processing of the Claim

1.5 The Use of the Help Feature

CHAPTER 2: HEALTH DATA STRUCTURE, COLLECTION AND STANDARDS

2.1 The Professionals Who Maintain and Use Health Information

2.2 Data Versus Information

2.3 Computer-Based Health Information Media

2.4 Screen-Based Data Collection Tools

2.5 Collecting Data Elements

2.6 Electronic Health (Medical) Records (EHR) (EMR)

2.7 Laws, Regulations, and Standards

2.8 The Similarities and Differences Between a Physician’s Office and Hospital Information Systems

CHAPTER 3: CONTENT OF THE HEALTH RECORD – ADMINISTRATIVE DATA

3.1 Administrative Data Elements

3.2 Administrative Uses of Data

3.3 The Master Patient (person) Index (MPI)

3.4 Registering a New Patient in PrimeSUITE

Exercise 3.1: Register a new patient [PM]

3.5 Scheduling an Appointment

Exercise 3.2: Schedule an appointment [PM]

3.6 Editing Demographic Data

Exercise 3.3: Edit demographic information [PM, EHR]

3.7 Checking in a Patient

Exercise 3.4: Check in a patient who has arrived [PM]

3.8 Capture Insurance Information

Exercise 3.5: Capture insurance information of a patient [PM, EHR]

3.9 Utilize the Help Feature

Exercise 3.6: Use the help feature [PM, EHR]

CHAPTER 4: CONTENT OF THE HEALTH RECORD – THE PAST MEDICAL, SURGICAL, FAMILY, AND SOCIAL HISTORY

4.1 Forms as Data Collection Tools

4.2 The Past Medical, Surgical, Family, and Social Histories

Exercise 4.1: Enter a patient’s past medical history [EHR]

Exercise 4.2: Enter a patient's list of current medications [EHR]

Exercise 4.3: Enter a patient's known drug allergies [EHR]

4.3 Handling Inconsistent or Unclear Information

4.4 Documenting Vital Signs

Exercise 4.4: Enter a patient's vital signs [EHR]

CHAPTER 5: CONTENT OF THE HEALTH RECORD – THE CARE PROVIDER’S RESPONSIBILITY

5.1 The SOAP Note

Exercise 5.1: Look up the patient’s plan of care [EHR]

5.2 The History of Present Illness (HPI)

Exercise 5.2: Locate Juan Ortega's blood pressure [EHR]

5.3 The Review of Systems (ROS)

5.4 The Physical Exam

5.5 Medical Dictation and Transcription

5.6 Voice (Speech) Recognition Technology

5.7 Electronic Prescribing (ePrescribing)

Exercise 5.3: Using ePrescribe [EHR]

5.8 Computerized Physician Order Entry (CPOE)

5.9 Tracking Physicians’ Orders

Exercise 5.4: Locate the status of an order [EHR]

5.10 The Problem List

Exercise 5.5: Utilizing the Problem List [EHR]

CHAPTER 6: FINANCIAL MANAGEMENT: INSURANCE AND BILLING FUNCTIONS

6.1 Claims Management – Why and How

6.2 Use of a Superbill

6.3 The Claims Process Using PrimeSUITE

Exercise 6.1: Post a copayment to an account [PM]

Exercise 6.2: Given a scenario, look up the status of an insurance claim [PM]

6.4 Diagnosis and Procedure Coding Using PrimeSUITE

6.5 The Relationship Between Documentation and Coding

Exercise 6.3: Enter diagnoses and procedures to locate ICD-9 and CPT codes [PM, EHR, HIM]

6.6 The Conversion to ICD-10-CM/PCS

6.7 Accounts Receivable—Getting Paid

6.8 Managing Accounts Receivable in PrimeSUITE

Exercise 6.4: Post an insurance payment to an account [PM]

6.9 Compliance

CHAPTER 7: PRIVACY, SECURITY, CONFIDENTIALITY AND LEGAL ISSUES

7.1 The HIPAA Privacy and Security Standards

7.2 Evaluating an EHR System for HIPAA Compliance

7.3 The Role of Certification EHR Implementation

7.4 Applying Security Measures

Exercise 7.1: Add new clinical users and assign password [PM, HIM]

Exercise 7.2: Set up a care provider [PM, HIM]

Exercise 7.3: Assign user rights to an MA [PM, HIM]

Exercise 7.4: Assign user rights to an office manager [PM, HIM]

Exercise 7.5: Create a group [PM, HIM]

Exercise 7.6: Set general security [PM, HIM]

Exercise 7.7: Run an audit trail report [PM, HIM]

7.5 Data Integrity

Exercise 7.8: Amend a chart entry [PM, EHR, HIM]

Exercise 7.9: Hide a chart entry[PM, EHR, HIM]

Exercise 7.10: Recover a hidden chart entry [PM, EHR, HIM]

7.6 Apply Policies and Procedures to Release Health Information using PrimeSUITE

Exercise 7.11: Compose a correspondence letter to accompany the release of a patient's immunization record [EHR, HIM]

7.7 Accounting of Information Disclosures

Exercise 7.12: Run a report of information disclosures for a particular patient [EHR, HIM]

7.8 Information Exchange

Exercise 7.13: Exchange of information for continuity of care [EHR, HIM]

7.9 Compliance Plans

7.10 Safeguarding Your System and Contingency Planning

CHAPTER 8: MANAGEMENT OF INFORMATION AND COMMUNICATION

8.1 Internal Communications

Exercise 8.1: Send an electronic message using PrimeSUITE messaging [PM, EHR, HIM]

8.2 Importing Documents to the EHR

Exercise 8.2: Scan an insurance card into a patient's record [PM, EHR, HIM]

8.3 Master Files and Templates

Exercise 8.3: Build a master file in PrimeSUITE [PM, EHR, HIM]

8.4 Customization

Exercise 8.4: Customize a facesheet screen [PM, EHR, HIM]

Exercise 8.5: Customize a clinical desktop [PM, EHR, HIM]

8.5 Using Software to Organize Your Work --Task Lists

Exercise 8.6: Create a task for the receptionist [PM, EHR, HIM]

8.6 Using Software as a Reminder

Exercise 8.7: Assign a flag to a patient's chart [PM, EHR, HIM]

CHAPTER 9: DECISION AND COMPLIANCE SUPPORT: UTILIZING THE DATABASE

9.1 Using the Dashboard in PrimeSUITE to meet Meaningful Use standards

Exercise 9.1: View a practice's dashboard [PM, EHR, HIM]

9.2 Data and Information Used in Decision Support

Exercise 9.2: Build a clinical alert, Part A [PM, EHR, HIM]

Exercise 9.3: Build a clinical alert, Part B [PM, EHR, HIM]

9.3 Use of Report-Writer for System Reports

Exercise 9.4: Run a report of all patients between the ages of 60 and 80 [PM, EHR, HIM]

9.4 Custom Report Writing

Exercise 9.5: Build a custom report of all patients with a diagnosis of 428.0 who are female and over the age of 60, Part A [PM, EHR, HIM]

Exercise 9.6: Build a custom report of all patients with a diagnosis of 428.0 who are female and over the age of 60, Part B [PM, EHR, HIM]

9.5 Uses of Indexes

9.6 Uses of Registries

9.7 The Credentialing Process

Chapter 10: LOOKING AHEAD – THE FUTURE OF HEALTH INFORMATION AND INFORMATICS

10.1 Health Information versus Health Informatics

10.2 Barriers to Adopting an Electronic Health Record

10.3 Emerging Technologies and Models

10.4 Making the World of Health Informatics User Friendly and Convenient

10.5 Virtual Private Networks – Advancing the Use of EHRs Remotely Yet Securely

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