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Question description

Learning Plan 3: The Electronic Medical Record

Competency

2. Use paper and simulated health records for patients. (Kinn’s Ch. 14)
a. Construct a paper medical file for a new patient according to the stated task, conditions, and standards listed in the learning outcome evaluation. (Kinn's Ch. 14, Procedure 14-1)
b. Add supplementary items to an established paper patient file according to the stated task, conditions, and standards listed in the learning outcome evaluation. (Kinn's C.h 14, Procedure 14-3)
c. Demonstrate making a correction to a handwritten entry in a patient file. (Kinn's Ch. 14)

3. Analyze an electronic health record management system. (Kinn’s 11th, Ch. 15, Gartee Ch. 1)

b. Describe the functions of electronic health records. (Kinn's Ch. 15)
c. Compare and contrast paper-based versus computer-based patient records. (Gartee Ch. 1)
d. Explain the importance of clinical standards in the development of interoperable electronic health records including authenticity, reproducibility, reliability, auditability, compliance, timelines, and security. (Kinn's Ch. 15)
e. Describe the intent of various health care regulations and standards. (Gartee Ch. 1)

Overview

During week 3, you will use documents to create and organize a new patient medical record. The previous two learning plans helped to provide you with an overview of the importance of the medical record. This week the main objective is to actually create one and to familiarize you with the components of Electronic Medical Records systems.
Chapter 2 in the Gartee’s Electronic Health Records text explains how the format in which EHR data is stored determines the potential uses of EHR data to improve patient care and safety.  This chapter describes the various forms of storing EHR data and the value of using standardized codes for that data.  The chapter covers the major EHR standard nomenclature and history, purpose, and relationship to each other. (Gartee)

Learning Activities

  1. Did you ever want to enter into a world of virtual reality?  Who would you be? What would you do? How would you think?  How would you work with others? Now is your time to answer those questions and enter into the virtual world of healthcare. How will you do this? You will begin this journey by using a Virtual Medical Office Simulation. Pretend you are a medical record and trace your steps from being “born” to being “retired”.
  2. READ/REVIEW the following:
    • Chapter 15 in Kinn’s The Medical Assistant textbook on pages 263-273.
    • Chapters 1 and 2 in Gartee’s Electronic Health Records on pages 1-76.
  3. REVIEW the Chapter 1Chapter 2, and Chapter 15 PowerPoint presentations.
  4. REVIEW (do not complete) Critical Thinking Exercise 7 in Gartee’s Electronic Health Records on pages 65-67: Scanned Lab Report. Think about how this functional lab component for ordering labs along with receiving and documenting the results, etc. within an EHR lends a hand in following clinical standards in terms of data and sources:
    • authentication
    • reliability
    • auditability
    • security
    • compliance
    • data reproduction
    • compliance
    • data and source reliability of information
    • timely receipt and documentation
    • checks and balances for tests ordered for patient care
  5. RECAP the content in this learning plan by reviewing the PowerPoint presentations, Chapters 1 and 2 summaries in Gartee’s Electronic Health Records, and Chapter 15 summary in Kinn’s The Medical Assistant.  Reflect on your overall comprehension from this learning plan by reviewing your ability to perform the following:
    • Define electronic health records
    • Understand the core functions of an Electronic Health Record as defined by the Institute of Medicine
    • Discuss social forces that are driving the adoption of electronic health records
    • Describe federal government strategies to promote EHR adoption
    • Explain why  electronic health records are important
    • Describe the flow of medical information into the chart
    • Compare the workflow of an office using paper charts with an office using an EHR
    • Contrast inpatient and outpatient charts
    • Explain why patient visits should be documented at the point of care
    • Compare various types of electronic health record computers such as workstation laptop and Tablet PC
    • Compare different formats of EHR data
    • Describe the importance of codified EHR
    • Have an understanding of prominent EHR code sets such as SNODMED-CT, MEDCIN, LOINC, and CCC
    • Explain different methods of capturing and recording EHR data
    • Catalog and retrieve documents and images from a digital image system
    • Discuss the exchange of data between EHR and other systems
    • Discuss the benefits of patient-entered data
    • Describe the functional benefits from a codified EHR
    • Compare different formats of lab result data
    • Discuss alert systems and drug utilization review
    • Describe two important components of health maintenance
    • Provide examples of EHR decision support
  6. PARTICIPATE in Discussion 3: Clinical Standards with the Help of Electronic Health Records.

Assignments

  1. COMPLETE the LP3.1 Assignment: Gartee Chapters 1 and 2.
  2. COMPLETE the LP3.2 Assignment: Procedure 15-1.

Tutor Answer

(Top Tutor) Daniel C.
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School: Duke University
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