Electronic health records: understanding and using computerized medical records
Saved in:
| Main Author: | |
|---|---|
| Format: | Book |
| Language: | English |
| Published: |
Upper Saddle River, N.J.
Pearson Prentice Hall
c2007
|
| Subjects: | |
| Online Access: | Table of contents only Inhaltsverzeichnis |
| Item Description: | Includes index. |
| Physical Description: | xxxii, 506 p. col. ill. 28 cm |
| ISBN: | 0131960792 |
Staff View
MARC
| LEADER | 00000nam a2200000zc 4500 | ||
|---|---|---|---|
| 001 | BV023062200 | ||
| 003 | DE-604 | ||
| 005 | 20080123 | ||
| 007 | t | ||
| 008 | 071222s2007 xxua||| |||| 00||| eng d | ||
| 010 | |a 2006001606 | ||
| 020 | |a 0131960792 |9 0-13-196079-2 | ||
| 035 | |a (OCoLC)63114195 | ||
| 035 | |a (DE-599)BVBBV023062200 | ||
| 040 | |a DE-604 |b ger |e aacr | ||
| 041 | 0 | |a eng | |
| 044 | |a xxu |c US | ||
| 049 | |a DE-1049 | ||
| 050 | 0 | |a R864 | |
| 082 | 0 | |a 651.5 | |
| 100 | 1 | |a Gartee, Richard |e Verfasser |4 aut | |
| 245 | 1 | 0 | |a Electronic health records |b understanding and using computerized medical records |c Richard Gartee |
| 264 | 1 | |a Upper Saddle River, N.J. |b Pearson Prentice Hall |c c2007 | |
| 300 | |a xxxii, 506 p. |b col. ill. |c 28 cm | ||
| 336 | |b txt |2 rdacontent | ||
| 337 | |b n |2 rdamedia | ||
| 338 | |b nc |2 rdacarrier | ||
| 500 | |a Includes index. | ||
| 650 | 4 | |a Dossiers médicaux - Informatique | |
| 650 | 4 | |a Datenverarbeitung | |
| 650 | 4 | |a Medical records |x Data processing | |
| 650 | 4 | |a Medical Records Systems, Computerized | |
| 650 | 4 | |a Forms and Records Control |x methods | |
| 856 | 4 | |u http://www.loc.gov/catdir/toc/ecip066/2006001606.html |3 Table of contents only | |
| 856 | 4 | 2 | |m HBZ Datenaustausch |q application/pdf |u http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=016265434&sequence=000008&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA |3 Inhaltsverzeichnis |
| 999 | |a oai:aleph.bib-bvb.de:BVB01-016265434 | ||
Record in the Search Index
| _version_ | 1804137300469219328 |
|---|---|
| adam_text | Contents
Preface xv
Introduction xv
Learning Made Easy xvi
Organization of the Text xvi
The Transfer of Acquired Skills to Actual EHR Systems xviii
A Few Words of Advice xix
About the Author xxv
Acknowledgments xxvii
Reviewers xxxi
Electronic Health Records—An Overview 1
What Are Electronic Health Records 2
Why Electronic Health Records Are Important 5
Health Maintenance 6
Trend Analysis 7
Alerts 7
Decision Support 7
Forces Driving toward EHR 8
Health and Safety 9
National Coordinator for Health Information Technology 10
Readiness for Change 10
Vision for Consumer Centric and Information Rich Care 11
Strategic Framework 11
Where s My Chart?—A Real Life Story 12
Building the EHR 15
Flow of Medical Information into the Chart 15
Flow of an Office Fully Using EHR 18
Transition to an EHR 21
Levels of EHR Implementation 22
Building the EHR In Steps 23
Comparing the EHR in an Inpatient versus Outpatient Setting 25
Methods of Capturing and Recording Data 27
Workflow of Physician Orders and Results 29
Lab Orders and Reports 29
Comparison of Lab Order and Results Workflow 29
Medication Orders 32
Radiology Orders and Reports 33
Electronic Data Interchange between Systems and Devices 34
HL7 34
CDISC 35
DICOM 35
Medical Devices 36
Chapter One Summary 36
Coding Standards 39
The Value of Codified Electronic Health Records 41
Forms of EHR Data 41
Limitations of Types of Data 42
Comparison of Lab Results 43
Alerts 46
Health Maintenance 46
Standard Coding Systems 47
Government Influence on Coding Standards 47
Comparison of Prominent EHR Code Sets 49
How EHR Nomenclatures Differ from Other Code Sets 49
SNOMED CT® 50
MEDCIN® 53
LOINC® 55
UMLS® 57
Nursing Code Sets 57
A Nurse s Notes—A Real Life Story 60
How EHR Code Sets Differ from Billing Code Sets 64
CPT 4® 64
ABC 65
ICD 9CM 65
ICD 10 67
NDC and Other Drug Codes 68
Conclusion 69
Chapter Two Summary 70
Learn n9 Medical Record Software 75
Introducing the Medcin Student Edition Software 76
Understanding the Software 77
Hands On Exercise 1: Starting Up the Software 77
Navigating the Screen 78
Hands On Exercise 2: Exiting And Restarting the software 80
Hands On Exercise 3: Using the Menu to Select a Patient 80
Hands On Exercise 4: Navigating the Medcin Findings 82
Hands On Exercise 5; Tabs on the Medcin Nomenclature Panel 85
Data Entry of the Examination Note 86
Hands On Exercise 6: Creating an Encounter 87
Hands On Exercise 7: Recording Subjective Findings 90
Hands On Exercise 8: Removing Findings 93
Hands On Exercise 9: Recording More Specific Findings 94
Hands On Exercise 10: Recording History Findings 95
Adding Details to the Findings 97
Hands On Exercise 11: Recording a Value 97
Using Free Text 98
Hands On Exercise 12: Adding Free text 98
Hands On Exercise 13: Recording Objective Findings 100
Hands On Exercise 14: Setting the Result Field 101
Hands On Exercise 15: Adding Detail to Recorded
Findings 102
Hands On Exercise 16: Adding Episode Detail to Findings 103
Hands On Exercise 17: Recording the Assessment 104
Hands On Exercise 18: Recording Treatment Plan
and Physician Orders 105
Introduction to Using Forms 107
Hands On Exercise 19: Recording the Chief Complaint 108
Hands On Exercise 20: Recording Vital Signs 109
Paperless in Less Than A Day—A Real Life Story 112
Applying Your Knowledge 114
Hands On Exercise 21: Documenting a Visit for Headaches 114
Hands On Exercise 22: Printing the Narrative Report 123
Chapter Three Summary 127
Data Entry at the Point of Care 131
Increased Familiarity with the Software 132
Documenting a Brief Patient Visit 132
Hands On Exercise 23: Documenting a Visit for Common Cold 132
Why Speed of Entry Is Important in the EHR 142
Methods to Increase Speed of Entry 143
Encounter Tab Toolbar 143
Search and Prompt Features 144
How Search Works 145
Hands On Exercise 24: Using Search 145
Hands On Exercise 25: Ordering Diagnostic Tests 152
Shortcuts That Increase Speed for Routine Exams 158
The Concept of Lists 159
Hands On Exercise 26: Using Adult URI List 160
Hands On Exercise 27: Writing Prescriptions in an EHR 169
Hands On Exercise 28: Timed Experiment for Extra Credit (Optional) 174
The Concept of Forms 174
Comparison of Lists and Forms 174
Standard Initial Visit Intake for Adult 176
Hands On Exercise 29: Using Forms 176
How I Learned to Stop Worrying and Love Forms—A Real Life Story 190
Chapter Four Summary 192
Electronic Coding from Medical Records 195
CPT 4 and ICD 9CM Codes for Billing 196
Understanding Evaluation and Management Codes 196
Using EHR Software to Calculate the Correct E M Code 197
Hands On Exercise 30: Calculating E M Code from an Exam 198
How the Level of an E M Code Is Determined 201
Key Component: History 202
How History May Be Documented 206
Key Component: Examination 207
Key Component: Medical Decision Making 209
Determining the Level of Medical Decision Making 214
Other Components: Counseling, Coordination of Care, and Time 214
Putting It All Together 216
Evaluating Key Components 216
Factors That Affect the E M Code Set 218
Hands On Exercise 31: Exploring the E M Calculator 218
Factors That Increase the Level of Codes 221
Fraud and Abuse 222
Hands On Exercise 32: Calculating E M for a More Complex Visit 222
Hands On Exercise 33: Counseling More Than 50%
of Face to Face Time 231
ICD 9CM Codes Justify Billing 235
Determine the Level of Specificity 237
Multiple Diagnosis Codes per Visit 237
A New Level of Efficiency in Addition to Improved E M Coding—A Real Life Story 238
Primary and Secondary Diagnoses 240
Medical Necessity 240
Ordering Tests to Confirm or Rule Out Diagnosis 240
How The ICD 9 Code Influences Orders and Treatment 241
Hands On Exercise 34: Orders Based on Diagnosis 241
Hands On Exercise 35: Multiple Diagnoses 248
Chapter Five Summary 254
Comprehensive Evaluation of Chapters 1 5 258
Part I Written Exam 258
Part ll Hands on Exercise 259
Hands On Exercise 36: Examination of a Patient
with Asthma 259
k Advanced Techniques Speed Data Entry 265
Improved Data Entry 266
Management of Patients Health 266
Understanding Problem Lists 267
Hands On Exercise 37: Exploring Patient Management 268
Citing Previous Visits from Problem Lists 277
Hands On Exercises 38: Following Up on a Problem 277
EHR Data from External Sources 285
Vital Signs 286
Diagnostic Tests 287
Electronic Lab Orders and Results 287
Workflow of Electronic Lab Orders and Results 288
Hands On Exercise 39: Viewing Pending Orders and Lab Results 290
Graphing Lab Results from the Chart 300
Hands On Exercise 40: Graphing Lab Results 300
Quick Access to Frequent Orders 304
Patient Entry of Symptoms and Previous History 304
Triage 305
The Clinicians Dilemma 305
Triage by Computer 306
Workflow Using Patient Entered Data 307
The First Patient Whose Life Was Saved by Expert System Software
He Operated Himself—A Real Life Story 310
Alternative Workflow 311
Improved Patient Information 311
Preventive Health Screening 311
Systems Integration for Better Patient Care 311
Chapter Six Summary 312
? Using the EHR to Improve Patient Care 316
Disease Management and Prevention 317
Flow Sheets 318
Hands On Exercise 41: Working with a Flow Sheet 318
About the Flow Sheet View 322
Hands On Exercise 42: Creating a Problem Oriented Flow Sheet 335
Patient Involvement in their Own Health Care 337
Hands On Exercise 43: Graphing Vital Signs in the Chart 337
Patient Entered Data Graphs 338
Prevention and Early Detection 340
Pediatric We 11 ness Visits 340
Hands On Exercise 44: A Well Baby Check Up 340
The Relation Between Vitals and Growth Charts 351
What Is a Percentile? 351
Body Mass Index 353
Optional Exercise 45: Calculate Your Own BMI 353
The Importance of Childhood Immunizations 353
Hands On Exercise 46: Immunizations 354
Immunization Schedules from the CDC 355
Optional Exercise 47: Determine Your Adult Immunizations 361
Preventative Care Screening 361
Quality Care for Pediatric and Adult Patients—A Real Life Story 363
Using EHR Data for Alerts 365
Reactions to Drugs or Other Treatments 366
Other Types of Alerts 368
Chapter Seven Summary 368
Privacy and Security of Health Records 371
Understanding HIPAA 372
HIPAA Transactions and Code Sets 373
HIPAA Uniform Identifiers 374
HIPAA Privacy Rule 374
Privacy Policy 375
Consent 376
Authorization 378
Government Agencies 379
Minimum Necessary 379
A Patient s Right to Know about Disclosures 380
Patient Access to Medical Records 380
Incidental Disclosures 381
Personal Representatives 381
Minor Children 382
Summary of Patient Privacy Rights 383
Business Associates 384
Civil and Criminal Penalties 386
HIPAA Security Rule 386
The First HIPAA Privacy Case—A Real Life Story 387
Why Security? 388
The Privacy Rule and Security Rule Compared 388
Security Standards 389
Implementation Specifications 389
Administrative Safeguards 390
Security Management Process 391
Assigned Security Responsibility 392
Workforce Security 392
Information Access Management 393
Security Awareness and Training 393
Security Incident Procedures 394
Contingency Plan 395
Evaluation 395
Business Associate Contracts and Other Arrangements 395
Physical Safeguards 395
Facility Access Controls 395
Workstation Use 396
Workstation Security 397
Device and Media Controls 397
Technical Safeguards 397
Access Control 397
Audit Controls 399
Integrity 399
Person or Entity Authentication 399
Transmission Security 400
Organizational, Policies and Procedures
and Documentation Requirements 400
Organizational Requirements 400
Policies and Procedures 401
Documentation 401
Electronic Signatures for Medical Records 401
What Is an Electronic Signature and What Is Not? 401
How Digital Signatures Work 403
Some Electronic Signatures Are Not Truly Signatures 404
The Future of Electronic Signatures 404
HIPAA Privacy, Security, and You 405
Hands On Exercise 48: Medical Office Privacy Policy 405
Chapter Eight Summary 405
EHR and Technology 410
How Technology Impacts Implementation of EHR 411
Style of Practice 412
The Physical Clinic and Clinician Mobility 413
EHR On Computer Workstations 413
EHR on Laptop Computers 414
EHR on a Tablet PC 415
EHR on Handheld PDA Devices 417
EHR Devices and the Patient 421
Remote EHR Access for the Provider 425
Enhancing Process Efficiency Through Remote Access—A Real Life Story 426
Speech Recognition 428
Including Annotated Drawings in the EHR 430
Hands On Exercise 49: Annotated Dermatology Exam 430
The Internet and the EHR 442
Decision Support 443
Provider to Patient E Mail Communication 443
Secure Messaging 445
E Visits 445
Workflow of an E Visit 446
Patient Access to Electronic Health Records 448
Optional Exercise 50: Creating Your Own Health Record 449
Chapter Nine Summary 449
Comprehensive Evaluation of Chapters 6 9 453
Part I Written Exam 453
Part Il Hands On Exercise 454
Hands On Exercise 51: Examination of A Patient
with Arterial Disease 454
CMS Documentation Guideline Tables 463
Information About the Student Edition
History Program 468
Instructions for Starting History Program Software 468
Stopping the History Program 470
Indications that the History Program Is Not Running 471
Glossary 473
Index 491
|
| adam_txt |
Contents
Preface xv
Introduction xv
Learning Made Easy xvi
Organization of the Text xvi
The Transfer of Acquired Skills to Actual EHR Systems xviii
A Few Words of Advice xix
About the Author xxv
Acknowledgments xxvii
Reviewers xxxi
Electronic Health Records—An Overview 1
What Are Electronic Health Records 2
Why Electronic Health Records Are Important 5
Health Maintenance 6
Trend Analysis 7
Alerts 7
Decision Support 7
Forces Driving toward EHR 8
Health and Safety 9
National Coordinator for Health Information Technology 10
Readiness for Change 10
Vision for Consumer Centric and Information Rich Care 11
Strategic Framework 11
Where's My Chart?—A Real Life Story 12
Building the EHR 15
Flow of Medical Information into the Chart 15
Flow of an Office Fully Using EHR 18
Transition to an EHR 21
Levels of EHR Implementation 22
Building the EHR In Steps 23
Comparing the EHR in an Inpatient versus Outpatient Setting 25
Methods of Capturing and Recording Data 27
Workflow of Physician Orders and Results 29
Lab Orders and Reports 29
Comparison of Lab Order and Results Workflow 29
Medication Orders 32
Radiology Orders and Reports 33
Electronic Data Interchange between Systems and Devices 34
HL7 34
CDISC 35
DICOM 35
Medical Devices 36
Chapter One Summary 36
Coding Standards 39
The Value of Codified Electronic Health Records 41
Forms of EHR Data 41
Limitations of Types of Data 42
Comparison of Lab Results 43
Alerts 46
Health Maintenance 46
Standard Coding Systems 47
Government Influence on Coding Standards 47
Comparison of Prominent EHR Code Sets 49
How EHR Nomenclatures Differ from Other Code Sets 49
SNOMED CT® 50
MEDCIN® 53
LOINC® 55
UMLS® 57
Nursing Code Sets 57
A Nurse's Notes—A Real Life Story 60
How EHR Code Sets Differ from Billing Code Sets 64
CPT 4® 64
ABC 65
ICD 9CM 65
ICD 10 67
NDC and Other Drug Codes 68
Conclusion 69
Chapter Two Summary 70
Learn'n9 Medical Record Software 75
Introducing the Medcin Student Edition Software 76
Understanding the Software 77
Hands On Exercise 1: Starting Up the Software 77
Navigating the Screen 78
Hands On Exercise 2: Exiting And Restarting the software 80
Hands On Exercise 3: Using the Menu to Select a Patient 80
Hands On Exercise 4: Navigating the Medcin Findings 82
Hands On Exercise 5; Tabs on the Medcin Nomenclature Panel 85
Data Entry of the Examination Note 86
Hands On Exercise 6: Creating an Encounter 87
Hands On Exercise 7: Recording Subjective Findings 90
Hands On Exercise 8: Removing Findings 93
Hands On Exercise 9: Recording More Specific Findings 94
Hands On Exercise 10: Recording History Findings 95
Adding Details to the Findings 97
Hands On Exercise 11: Recording a Value 97
Using Free Text 98
Hands On Exercise 12: Adding Free text 98
Hands On Exercise 13: Recording Objective Findings 100
Hands On Exercise 14: Setting the Result Field 101
Hands On Exercise 15: Adding Detail to Recorded
Findings 102
Hands On Exercise 16: Adding Episode Detail to Findings 103
Hands On Exercise 17: Recording the Assessment 104
Hands On Exercise 18: Recording Treatment Plan
and Physician Orders 105
Introduction to Using Forms 107
Hands On Exercise 19: Recording the Chief Complaint 108
Hands On Exercise 20: Recording Vital Signs 109
Paperless in Less Than A Day—A Real Life Story 112
Applying Your Knowledge 114
Hands On Exercise 21: Documenting a Visit for Headaches 114
Hands On Exercise 22: Printing the Narrative Report 123
Chapter Three Summary 127
Data Entry at the Point of Care 131
Increased Familiarity with the Software 132
Documenting a Brief Patient Visit 132
Hands On Exercise 23: Documenting a Visit for Common Cold 132
Why Speed of Entry Is Important in the EHR 142
Methods to Increase Speed of Entry 143
Encounter Tab Toolbar 143
Search and Prompt Features 144
How Search Works 145
Hands On Exercise 24: Using Search 145
Hands On Exercise 25: Ordering Diagnostic Tests 152
Shortcuts That Increase Speed for Routine Exams 158
The Concept of Lists 159
Hands On Exercise 26: Using Adult URI List 160
Hands On Exercise 27: Writing Prescriptions in an EHR 169
Hands On Exercise 28: Timed Experiment for Extra Credit (Optional) 174
The Concept of Forms 174
Comparison of Lists and Forms 174
Standard Initial Visit Intake for Adult 176
Hands On Exercise 29: Using Forms 176
How I Learned to Stop Worrying and Love Forms—A Real Life Story 190
Chapter Four Summary 192
Electronic Coding from Medical Records 195
CPT 4 and ICD 9CM Codes for Billing 196
Understanding Evaluation and Management Codes 196
Using EHR Software to Calculate the Correct E M Code 197
Hands On Exercise 30: Calculating E M Code from an Exam 198
How the Level of an E M Code Is Determined 201
Key Component: History 202
How History May Be Documented 206
Key Component: Examination 207
Key Component: Medical Decision Making 209
Determining the Level of Medical Decision Making 214
Other Components: Counseling, Coordination of Care, and Time 214
Putting It All Together 216
Evaluating Key Components 216
Factors That Affect the E M Code Set 218
Hands On Exercise 31: Exploring the E M Calculator 218
Factors That Increase the Level of Codes 221
Fraud and Abuse 222
Hands On Exercise 32: Calculating E M for a More Complex Visit 222
Hands On Exercise 33: Counseling More Than 50%
of Face to Face Time 231
ICD 9CM Codes Justify Billing 235
Determine the Level of Specificity 237
Multiple Diagnosis Codes per Visit 237
A New Level of Efficiency in Addition to Improved E M Coding—A Real Life Story 238
Primary and Secondary Diagnoses 240
Medical Necessity 240
Ordering Tests to Confirm or Rule Out Diagnosis 240
How The ICD 9 Code Influences Orders and Treatment 241
Hands On Exercise 34: Orders Based on Diagnosis 241
Hands On Exercise 35: Multiple Diagnoses 248
Chapter Five Summary 254
Comprehensive Evaluation of Chapters 1 5 258
Part I Written Exam 258
Part ll Hands on Exercise 259
Hands On Exercise 36: Examination of a Patient
with Asthma 259
k Advanced Techniques Speed Data Entry 265
Improved Data Entry 266
Management of Patients' Health 266
Understanding Problem Lists 267
Hands On Exercise 37: Exploring Patient Management 268
Citing Previous Visits from Problem Lists 277
Hands On Exercises 38: Following Up on a Problem 277
EHR Data from External Sources 285
Vital Signs 286
Diagnostic Tests 287
Electronic Lab Orders and Results 287
Workflow of Electronic Lab Orders and Results 288
Hands On Exercise 39: Viewing Pending Orders and Lab Results 290
Graphing Lab Results from the Chart 300
Hands On Exercise 40: Graphing Lab Results 300
Quick Access to Frequent Orders 304
Patient Entry of Symptoms and Previous History 304
Triage 305
The Clinicians' Dilemma 305
Triage by Computer 306
Workflow Using Patient Entered Data 307
The First Patient Whose Life Was Saved by Expert System Software
He Operated Himself—A Real Life Story 310
Alternative Workflow 311
Improved Patient Information 311
Preventive Health Screening 311
Systems Integration for Better Patient Care 311
Chapter Six Summary 312
? Using the EHR to Improve Patient Care 316
Disease Management and Prevention 317
Flow Sheets 318
Hands On Exercise 41: Working with a Flow Sheet 318
About the Flow Sheet View 322
Hands On Exercise 42: Creating a Problem Oriented Flow Sheet 335
Patient Involvement in their Own Health Care 337
Hands On Exercise 43: Graphing Vital Signs in the Chart 337
Patient Entered Data Graphs 338
Prevention and Early Detection 340
Pediatric We 11 ness Visits 340
Hands On Exercise 44: A Well Baby Check Up 340
The Relation Between Vitals and Growth Charts 351
What Is a Percentile? 351
Body Mass Index 353
Optional Exercise 45: Calculate Your Own BMI 353
The Importance of Childhood Immunizations 353
Hands On Exercise 46: Immunizations 354
Immunization Schedules from the CDC 355
Optional Exercise 47: Determine Your Adult Immunizations 361
Preventative Care Screening 361
Quality Care for Pediatric and Adult Patients—A Real Life Story 363
Using EHR Data for Alerts 365
Reactions to Drugs or Other Treatments 366
Other Types of Alerts 368
Chapter Seven Summary 368
Privacy and Security of Health Records 371
Understanding HIPAA 372
HIPAA Transactions and Code Sets 373
HIPAA Uniform Identifiers 374
HIPAA Privacy Rule 374
Privacy Policy 375
Consent 376
Authorization 378
Government Agencies 379
Minimum Necessary 379
A Patient's Right to Know about Disclosures 380
Patient Access to Medical Records 380
Incidental Disclosures 381
Personal Representatives 381
Minor Children 382
Summary of Patient Privacy Rights 383
Business Associates 384
Civil and Criminal Penalties 386
HIPAA Security Rule 386
The First HIPAA Privacy Case—A Real Life Story 387
Why Security? 388
The Privacy Rule and Security Rule Compared 388
Security Standards 389
Implementation Specifications 389
Administrative Safeguards 390
Security Management Process 391
Assigned Security Responsibility 392
Workforce Security 392
Information Access Management 393
Security Awareness and Training 393
Security Incident Procedures 394
Contingency Plan 395
Evaluation 395
Business Associate Contracts and Other Arrangements 395
Physical Safeguards 395
Facility Access Controls 395
Workstation Use 396
Workstation Security 397
Device and Media Controls 397
Technical Safeguards 397
Access Control 397
Audit Controls 399
Integrity 399
Person or Entity Authentication 399
Transmission Security 400
Organizational, Policies and Procedures
and Documentation Requirements 400
Organizational Requirements 400
Policies and Procedures 401
Documentation 401
Electronic Signatures for Medical Records 401
What Is an Electronic Signature and What Is Not? 401
How Digital Signatures Work 403
Some Electronic Signatures Are Not Truly Signatures 404
The Future of Electronic Signatures 404
HIPAA Privacy, Security, and You 405
Hands On Exercise 48: Medical Office Privacy Policy 405
Chapter Eight Summary 405
EHR and Technology 410
How Technology Impacts Implementation of EHR 411
Style of Practice 412
The Physical Clinic and Clinician Mobility 413
EHR On Computer Workstations 413
EHR on Laptop Computers 414
EHR on a Tablet PC 415
EHR on Handheld PDA Devices 417
EHR Devices and the Patient 421
Remote EHR Access for the Provider 425
Enhancing Process Efficiency Through Remote Access—A Real Life Story 426
Speech Recognition 428
Including Annotated Drawings in the EHR 430
Hands On Exercise 49: Annotated Dermatology Exam 430
The Internet and the EHR 442
Decision Support 443
Provider to Patient E Mail Communication 443
Secure Messaging 445
E Visits 445
Workflow of an E Visit 446
Patient Access to Electronic Health Records 448
Optional Exercise 50: Creating Your Own Health Record 449
Chapter Nine Summary 449
Comprehensive Evaluation of Chapters 6 9 453
Part I Written Exam 453
Part Il Hands On Exercise 454
Hands On Exercise 51: Examination of A Patient
with Arterial Disease 454
CMS Documentation Guideline Tables 463
Information About the Student Edition
History Program 468
Instructions for Starting History Program Software 468
Stopping the History Program 470
Indications that the History Program Is Not Running 471
Glossary 473
Index 491 |
| any_adam_object | 1 |
| any_adam_object_boolean | 1 |
| author | Gartee, Richard |
| author_facet | Gartee, Richard |
| author_role | aut |
| author_sort | Gartee, Richard |
| author_variant | r g rg |
| building | Verbundindex |
| bvnumber | BV023062200 |
| callnumber-first | R - Medicine |
| callnumber-label | R864 |
| callnumber-raw | R864 |
| callnumber-search | R864 |
| callnumber-sort | R 3864 |
| callnumber-subject | R - General Medicine |
| ctrlnum | (OCoLC)63114195 (DE-599)BVBBV023062200 |
| dewey-full | 651.5 |
| dewey-hundreds | 600 - Technology (Applied sciences) |
| dewey-ones | 651 - Office services |
| dewey-raw | 651.5 |
| dewey-search | 651.5 |
| dewey-sort | 3651.5 |
| dewey-tens | 650 - Management and auxiliary services |
| discipline | Wirtschaftswissenschaften |
| discipline_str_mv | Wirtschaftswissenschaften |
| format | Book |
| fullrecord | <?xml version="1.0" encoding="UTF-8"?><collection xmlns="http://www.loc.gov/MARC21/slim"><record><leader>01482nam a2200397zc 4500</leader><controlfield tag="001">BV023062200</controlfield><controlfield tag="003">DE-604</controlfield><controlfield tag="005">20080123 </controlfield><controlfield tag="007">t</controlfield><controlfield tag="008">071222s2007 xxua||| |||| 00||| eng d</controlfield><datafield tag="010" ind1=" " ind2=" "><subfield code="a">2006001606</subfield></datafield><datafield tag="020" ind1=" " ind2=" "><subfield code="a">0131960792</subfield><subfield code="9">0-13-196079-2</subfield></datafield><datafield tag="035" ind1=" " ind2=" "><subfield code="a">(OCoLC)63114195</subfield></datafield><datafield tag="035" ind1=" " ind2=" "><subfield code="a">(DE-599)BVBBV023062200</subfield></datafield><datafield tag="040" ind1=" " ind2=" "><subfield code="a">DE-604</subfield><subfield code="b">ger</subfield><subfield code="e">aacr</subfield></datafield><datafield tag="041" ind1="0" ind2=" "><subfield code="a">eng</subfield></datafield><datafield tag="044" ind1=" " ind2=" "><subfield code="a">xxu</subfield><subfield code="c">US</subfield></datafield><datafield tag="049" ind1=" " ind2=" "><subfield code="a">DE-1049</subfield></datafield><datafield tag="050" ind1=" " ind2="0"><subfield code="a">R864</subfield></datafield><datafield tag="082" ind1="0" ind2=" "><subfield code="a">651.5</subfield></datafield><datafield tag="100" ind1="1" ind2=" "><subfield code="a">Gartee, Richard</subfield><subfield code="e">Verfasser</subfield><subfield code="4">aut</subfield></datafield><datafield tag="245" ind1="1" ind2="0"><subfield code="a">Electronic health records</subfield><subfield code="b">understanding and using computerized medical records</subfield><subfield code="c">Richard Gartee</subfield></datafield><datafield tag="264" ind1=" " ind2="1"><subfield code="a">Upper Saddle River, N.J.</subfield><subfield code="b">Pearson Prentice Hall</subfield><subfield code="c">c2007</subfield></datafield><datafield tag="300" ind1=" " ind2=" "><subfield code="a">xxxii, 506 p.</subfield><subfield code="b">col. ill.</subfield><subfield code="c">28 cm</subfield></datafield><datafield tag="336" ind1=" " ind2=" "><subfield code="b">txt</subfield><subfield code="2">rdacontent</subfield></datafield><datafield tag="337" ind1=" " ind2=" "><subfield code="b">n</subfield><subfield code="2">rdamedia</subfield></datafield><datafield tag="338" ind1=" " ind2=" "><subfield code="b">nc</subfield><subfield code="2">rdacarrier</subfield></datafield><datafield tag="500" ind1=" " ind2=" "><subfield code="a">Includes index.</subfield></datafield><datafield tag="650" ind1=" " ind2="4"><subfield code="a">Dossiers médicaux - Informatique</subfield></datafield><datafield tag="650" ind1=" " ind2="4"><subfield code="a">Datenverarbeitung</subfield></datafield><datafield tag="650" ind1=" " ind2="4"><subfield code="a">Medical records</subfield><subfield code="x">Data processing</subfield></datafield><datafield tag="650" ind1=" " ind2="4"><subfield code="a">Medical Records Systems, Computerized</subfield></datafield><datafield tag="650" ind1=" " ind2="4"><subfield code="a">Forms and Records Control</subfield><subfield code="x">methods</subfield></datafield><datafield tag="856" ind1="4" ind2=" "><subfield code="u">http://www.loc.gov/catdir/toc/ecip066/2006001606.html</subfield><subfield code="3">Table of contents only</subfield></datafield><datafield tag="856" ind1="4" ind2="2"><subfield code="m">HBZ Datenaustausch</subfield><subfield code="q">application/pdf</subfield><subfield code="u">http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=016265434&sequence=000008&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA</subfield><subfield code="3">Inhaltsverzeichnis</subfield></datafield><datafield tag="999" ind1=" " ind2=" "><subfield code="a">oai:aleph.bib-bvb.de:BVB01-016265434</subfield></datafield></record></collection> |
| id | DE-604.BV023062200 |
| illustrated | Illustrated |
| index_date | 2024-07-02T19:29:21Z |
| indexdate | 2024-07-09T21:10:06Z |
| institution | BVB |
| isbn | 0131960792 |
| language | English |
| lccn | 2006001606 |
| oai_aleph_id | oai:aleph.bib-bvb.de:BVB01-016265434 |
| oclc_num | 63114195 |
| open_access_boolean | |
| owner | DE-1049 |
| owner_facet | DE-1049 |
| physical | xxxii, 506 p. col. ill. 28 cm |
| publishDate | 2007 |
| publishDateSearch | 2007 |
| publishDateSort | 2007 |
| publisher | Pearson Prentice Hall |
| record_format | marc |
| spelling | Gartee, Richard Verfasser aut Electronic health records understanding and using computerized medical records Richard Gartee Upper Saddle River, N.J. Pearson Prentice Hall c2007 xxxii, 506 p. col. ill. 28 cm txt rdacontent n rdamedia nc rdacarrier Includes index. Dossiers médicaux - Informatique Datenverarbeitung Medical records Data processing Medical Records Systems, Computerized Forms and Records Control methods http://www.loc.gov/catdir/toc/ecip066/2006001606.html Table of contents only HBZ Datenaustausch application/pdf http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=016265434&sequence=000008&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA Inhaltsverzeichnis |
| spellingShingle | Gartee, Richard Electronic health records understanding and using computerized medical records Dossiers médicaux - Informatique Datenverarbeitung Medical records Data processing Medical Records Systems, Computerized Forms and Records Control methods |
| title | Electronic health records understanding and using computerized medical records |
| title_auth | Electronic health records understanding and using computerized medical records |
| title_exact_search | Electronic health records understanding and using computerized medical records |
| title_exact_search_txtP | Electronic health records understanding and using computerized medical records |
| title_full | Electronic health records understanding and using computerized medical records Richard Gartee |
| title_fullStr | Electronic health records understanding and using computerized medical records Richard Gartee |
| title_full_unstemmed | Electronic health records understanding and using computerized medical records Richard Gartee |
| title_short | Electronic health records |
| title_sort | electronic health records understanding and using computerized medical records |
| title_sub | understanding and using computerized medical records |
| topic | Dossiers médicaux - Informatique Datenverarbeitung Medical records Data processing Medical Records Systems, Computerized Forms and Records Control methods |
| topic_facet | Dossiers médicaux - Informatique Datenverarbeitung Medical records Data processing Medical Records Systems, Computerized Forms and Records Control methods |
| url | http://www.loc.gov/catdir/toc/ecip066/2006001606.html http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=016265434&sequence=000008&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA |
| work_keys_str_mv | AT garteerichard electronichealthrecordsunderstandingandusingcomputerizedmedicalrecords |