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Problem Lists, Results Management, and Trending

The EHR provides many benefits. This resource discusses the use of Problem Lists, Results Management, and Trending features of the EHR and identifies how they are important tools for the physician in following patient problems, orders, medications, and disease progression or improvement.

After completing this resource, learners will be able to:

  • Create a graph of lab results and vital signs in the chart
  • View pending orders and lab test results
  • Use Problem Lists
  • Use Patient Management
Data Entry Using Flow Sheets and Anatomical Drawings

When patients have an ongoing health problem or chronic disease, it is useful for the clinician to compare the health data in the record from past patient visits. This is quickly and easily done using Flow Sheets. This resource discusses how Flow Sheets are used and how clinicians can quickly enter data during a patient encounter by updating similar data from a previous encounter. Additionally, clinicians often find it useful to be able to annotate an anatomical drawing of a body region to be clearer in describing the location of findings, such as dermatological conditions.

This resource discusses how to invoke anatomical drawings and annotate them using a variety of drawing tools.

After completing this resource, learners will be able to:

  • Use an EHR drawing tool to annotate drawings in an encounter
  • Create a Problem-Based flow sheet
  • Create a Form-Based flow sheet
  • Work with flow sheets in the EHR system
Using the Internet to Expedite Patient Care

The Internet changes the way people work and continues to transform what we can do with technology. This is especially true in healthcare. Using the Internet, providers can access patient electronic records from anywhere, communicate with their patients using email and instant messaging, transmit and view diagnostic images. These features facilitate the timeliness of patient care and work from any location. Patients can access their own health records, complete required forms and submit health information for ongoing health monitoring, and communicate with their providers.

As technologies associated with electronic health records and patient care develop, there will surely be additional features that use the Internet. This resource provides an overview of the use of the Internet and patient healthcare.

After completing this resource, learners will be able to:

  • Describe Personal Health Records (PHR)
  • Compare different types of telemedicine
  • Explain remote access and secure internet communications
  • Discuss issues related to security of Internet data
  • Compare the Internet to a private network
  • Explain how EHR systems use the Internet
Fundamentals of Information Systems and Healthcare Records

Although a health information professional deals mainly with the information in the healthcare system, it is important to understand a fair amount about computer systems, including hardware, software, and electronic communications, and how they support the exchange of data electronically. You must become competent in many aspects of technology in order to use it efficiently and effectively.

This resource reviews the computer technology that is the foundation of the electronic health record. Additionally, it provides an overview of the health record itself.

After completing this resource, learners will be able to:

  • Describe the various forms of telemedicine
  • Discuss the functions of healthcare records
  • Explain the fundamental concepts of computers and computer networks
Comparison of Paper and Electronic Records

Medical professionals are highly dependent on accurate and properly documented health information so that physicians and other health professionals can provide high quality care to patients. Primary among these, is the patient health record. If they haven't already, all medical facilities are transitioning from hard-copy, paper records to electronic health records. Regardless of what form they take, all patient health records contain a uniform set of information about the patient.

This resource discusses the various ways in which paper records are organized and stored as well as the numerous systems in which facilities identify their patients. The features, advantages, and disadvantages of the paper record are then compared to the electronic health record.

After completing this resource, learners will be able to:

  • Describe the workflow of an office fully using EHRS
  • Compare different forms and features of EHR data
  • Explain the importance of electronic health records
  • Discuss the HIM responsibilities of the legal health record
  • Explain the processes involved in document imaging
  • Describe the workflow of charts in the HIM department
  • Explain the various ways in which paper records are organized and stored