Items
Details
Table of Contents
1. Electronic health records: an overview : Evolution of electronic health records ; Social forces driving EHR adoption ; Government response ; Meaningful use of a certified EHR ; Why electronic health records are important ; Flow of clinical information into the chart ; Inpatient charts versus outpatient charts ; Documenting at the point of care
2. Functional EHR systems : Format of data determines potential benefits ; Standard EHR coding systems ; Capturing and recording EHR data ; Functional benefits from codified records ; Meeting the IOM definition of an EHR
3. Learning medical record software : Introducing the Medcin student edition software ; EHR login ; Understanding the software ; Navigating the screen ; Data entry of clinical notes ; Adding details to the findings ; Using free text ; Introduction to using forms
4. Increased familiarity with the software : Applying your knowledge ; Creating your first complete encounter note ; Creating an initial chart upon admission
5. Data entry at the point of care : Why speed of entry is important in the EHR ; Lists and forms speed data entry ; Shortcuts that speed documentation of typical cases ; The concept of lists ; The concept of forms ; Initial intake form for an adult ; Customized forms
6. Electronic nursing care plans : Nursing care plans ; Bringing the EHR to nursing ; CCC system ; Standard nursing plans of care ; Individualized plans of care ; Flow of the CCC model ; The interactive nursing plan of care ; Reassess and modify plan
7. Understanding electronic orders : The importance of electronic orders and results ; Recording orders in the student edition ; Lab orders and reports ; Comparison of orders and results workflows ; Learning to use the search and prompt features ; Radiology orders and reports ; Medication orders ; Quick access to frequent orders ; Protocols based on diagnosis codes ; Using diagnosis to find orders and treatments
8. Problem lists, results management, and trending : Longitudinal records to manage clients' health ; Understanding problem lists ; Citing previous visits from problem lists ; Orders and results management ; Trending ; Visual aides to engage clients in their own healthcare
9. Data entry using flow sheets and anatomical drawings : Learning to use flow sheets ; Use of anatomical drawings in the EHR ; Annotated drawings as EHR data
10. Subacute care, nursing homes, and home care : Postdischarge nursing care ; Assessment instruments ; Nursing homes ; Resident assessment instrument ; Home health care ; OASIS ; Data the nurse needs
11. Using the Internet to expedite care : The impact of technology ; The Internet and the EHR ; Decision support via the web ; Understanding the Internet ; Practicing medicine online ; Telemedicine ; Entry of symptoms and history by the client ; Provider-to-patient e-mail communication ; E-visits
12. Using the EHR for prevention and health maintenance : Prevention and early detection ; Pediatric wellness visits ; Understanding growth charts ; Body mass index ; The importance of childhood immunizations ; Client involvement in their own healthcare ; Preventative care screening ; Client access to electronic health records ; The personal history record.
2. Functional EHR systems : Format of data determines potential benefits ; Standard EHR coding systems ; Capturing and recording EHR data ; Functional benefits from codified records ; Meeting the IOM definition of an EHR
3. Learning medical record software : Introducing the Medcin student edition software ; EHR login ; Understanding the software ; Navigating the screen ; Data entry of clinical notes ; Adding details to the findings ; Using free text ; Introduction to using forms
4. Increased familiarity with the software : Applying your knowledge ; Creating your first complete encounter note ; Creating an initial chart upon admission
5. Data entry at the point of care : Why speed of entry is important in the EHR ; Lists and forms speed data entry ; Shortcuts that speed documentation of typical cases ; The concept of lists ; The concept of forms ; Initial intake form for an adult ; Customized forms
6. Electronic nursing care plans : Nursing care plans ; Bringing the EHR to nursing ; CCC system ; Standard nursing plans of care ; Individualized plans of care ; Flow of the CCC model ; The interactive nursing plan of care ; Reassess and modify plan
7. Understanding electronic orders : The importance of electronic orders and results ; Recording orders in the student edition ; Lab orders and reports ; Comparison of orders and results workflows ; Learning to use the search and prompt features ; Radiology orders and reports ; Medication orders ; Quick access to frequent orders ; Protocols based on diagnosis codes ; Using diagnosis to find orders and treatments
8. Problem lists, results management, and trending : Longitudinal records to manage clients' health ; Understanding problem lists ; Citing previous visits from problem lists ; Orders and results management ; Trending ; Visual aides to engage clients in their own healthcare
9. Data entry using flow sheets and anatomical drawings : Learning to use flow sheets ; Use of anatomical drawings in the EHR ; Annotated drawings as EHR data
10. Subacute care, nursing homes, and home care : Postdischarge nursing care ; Assessment instruments ; Nursing homes ; Resident assessment instrument ; Home health care ; OASIS ; Data the nurse needs
11. Using the Internet to expedite care : The impact of technology ; The Internet and the EHR ; Decision support via the web ; Understanding the Internet ; Practicing medicine online ; Telemedicine ; Entry of symptoms and history by the client ; Provider-to-patient e-mail communication ; E-visits
12. Using the EHR for prevention and health maintenance : Prevention and early detection ; Pediatric wellness visits ; Understanding growth charts ; Body mass index ; The importance of childhood immunizations ; Client involvement in their own healthcare ; Preventative care screening ; Client access to electronic health records ; The personal history record.