Learning Plan 4: Learning and Increasing Familiarity with Medical Record Software
3. Analyze an electronic health record management system. (Kinn’s 11th, Ch. 15, Gartee Ch. 1)
a. Describe factors that led to the emergence of electronic health records. (Kinn's Ch. 15)
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)
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)
4. Use electronic health records for patients (Kinn’s Ch. 15, Gartee Ch. 3-9, 12)
Construct an electronic medical file for a new patient according to the
stated task, conditions, and standards listed in the learning outcome
b. Demonstrate the use of each of the parts used in an electronic medical record. (Gartee)
Add supplementary items to an established electronic patient file
according to the stated task, conditions, and standards listed in the
learning outcome evaluation. (Gartee)
d. Demonstrate making a correction to an electronic entry in a patient file. (Kinn's Ch. 15)
e. Utilize information technology and medical terms as they apply to electronic health records. (Kinn's Ch. 15)
In week 4, we continue to build our understanding of the medical
record by learning how they are maintained. You will continue to
practice different methods of filing and organizing files. Now that we
have learned how to create a medical record, our main objective is to
learn efficient filing methods using both alphabetic and numeric filing
systems. You will also continue navigating through the Gartee Electronic
Medical Records exercises. The chapters used in this learning plan
contain a series of brief hands-on exercises that will assist you in
becoming familiar with EHR concepts and learning to navigate the
software. You will also learn how to save your work as printed
encounters to a PDF or XPS file. (Gartee)
- You have been chosen to lead a team of other staff members to
research EMR systems. In Gartee’s Electronic Medical Records, please
review the Real-Life Story “Paperless in Less than a Day” on page 113. Think about how you would sell your co-workers on the idea of using an EMR system.
- READ/REVIEW Chapters 3 and 4 in Gartee's Electronic Health Records.
- REVIEW the Chapter 3 and Chapter 4 PowerPoint presentations.
- REVIEW Real-Life Story “A Nurse’s Notes” on pages 144-145 in
Gartee’s Electronic Health Records. How would you work with the doctor
to assist his or her learning the technology of an EMR system? How did
the nurse’s experiences with the EHR differ from the doctor’s
experiences that you learned about in Chapter 3? What surprised you the
most about Sharyl Beal’s story?
- RECAP the content in this learning plan by reviewing the PowerPoint
presentations, and the Chapter 3 and 4 summaries in Gartee’s Electronic
Health Records. Reflect on your overall comprehension from this learning
plan by reviewing your ability to perform the following:
- Start and stop the Student Edition software
- Navigate the screen
- Select a patient
- Create a new encounter
- Document a patient visit
- Access the Symptoms, History, Physical Exam, Assessment, and Therapy
tabs to add appropriate findings in each portion of the exam
- Select findings for edit and remove findings
- Add entry details, values, free text, results, status, and episodes to findings
- Enter a chief complaint
- Enter vital signs
- Print a copy of the completed encounter note
- PARTICIPATE in Discussion 4: From Paper to Paperless.
- COMPLETE the LP4.1 Quiz: Gartee Chapter 3.
- COMPLETE the LP4.2 Quiz: Gartee Chapter 4.
- COMPLETE the LP4.1 Assignment: Rosa Garcia EHR Guided Exercise.
- COMPLETE the LP4.2 Assignment: Harold Baker EHR Guided Exercise.
- COMPLETE the LP4.3 Assignment: Charles Green EHR Critical Thinking Exercise.