Additional Information
Book Details
Abstract
Get hands-on practice with entering data into the Electronic Health Record! The Electronic Health Record for the Physician’s Office, 2nd Edition uses online simulations to walk you through each EHR task. Clear, step-by-step guidelines simplify the exercises in each simulation, so you learn all the EHR skills required of a medical office professional. This edition adds in-depth review and preparation for the Certified Electronic Health Records Specialist (CEHRS) examination. Written by Medical Assisting educator Julie Pepper, this how-to manual helps you master the administrative, clinical, and billing/coding skills you need to gain certification and succeed on the job. Access to SimChart for the Medical Office sold separately.
- Use of SimChart for the Medical Office (SCMO) for all EHR/practice management applications makes it easier to learn and apply EHR fundamentals.
- Realistic, hands-on practice helps you develop EHR skills including implementation, HIPAA compliance, troubleshooting, and submitting claims for reimbursement.
- Safe learning environment allows you to learn and practice tasks without fear of making a mistake affecting real patients.Â
- A guided tour through SCMO shows how to use the online simulations and practice EHR tasks.
- Application exercises in the appendix cover administrative, clinical, and insurance/billing, allowing you to practice the skills learned in the text.
- Student learning resources on the Evolve companion website include form upload, cases, additional insurance cards, and patient information forms, all providing additional practice.
- NEW! Enhanced EHR coverage provides in-depth preparation for the CEHRS examination.
- NEW! CEHRS examination preparation tools are included on Evolve.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | Cover | ||
| The ELECTRONIC HEALTH RECORD for the Physician’s Office | i | ||
| Copyright | ii | ||
| ACKNOWLEDGMENTS | iii | ||
| PREFACE | iv | ||
| ORGANIZATION | iv | ||
| DISTINCTIVE FEATURES | iv | ||
| LEARNING AIDS | iv | ||
| NEW TO THIS EDITION | iv | ||
| ANCILLARIES | iv | ||
| For the Student | iv | ||
| For the Instructor | v | ||
| CONTENTS | vi | ||
| 1 - Introduction to Electronic Health Records | 1 | ||
| WHAT IS A MEDICAL RECORD? | 2 | ||
| History of Medical Records | 2 | ||
| Content of the Electronic Health Record | 3 | ||
| Clinical Information | 3 | ||
| Administrative Information | 4 | ||
| Legal Documents | 4 | ||
| WHO DOCUMENTS IN THE MEDICAL RECORD? | 4 | ||
| WHO OWNS THE MEDICAL RECORD? | 6 | ||
| THE ELECTRONIC HEALTH RECORD | 7 | ||
| Transitioning from Paper to Electronic Records | 7 | ||
| What Is the Difference Between an Electronic Health Record and an Electronic Medical Record? | 8 | ||
| Electronic Health Records Software | 8 | ||
| Basic Functions | 8 | ||
| Clinical Decision Support | 9 | ||
| Practice Management Software | 9 | ||
| Patient Demographics | 9 | ||
| Billing and Insurance Information | 10 | ||
| Appointment Scheduling | 11 | ||
| Advanced Accounting Procedures | 11 | ||
| ADVANTAGES OF ELECTRONIC HEALTH RECORDS | 11 | ||
| Improved Quality and Continuity of Care | 11 | ||
| Managing Patients with Chronic Conditions | 11 | ||
| Disaster Preparedness and Response | 11 | ||
| Increased Efficiency | 12 | ||
| Improved Documentation | 13 | ||
| Why Document Properly? | 13 | ||
| Easier Accessibility at the Point of Care | 14 | ||
| Better Security | 14 | ||
| Reduced Expenses | 14 | ||
| Improved Job Satisfaction | 14 | ||
| Providers | 15 | ||
| Staff | 15 | ||
| Improved Patient Satisfaction | 15 | ||
| DISADVANTAGES OF ELECTRONIC HEALTH RECORDS | 15 | ||
| Lack of Interoperability | 15 | ||
| Cost | 16 | ||
| Financial Investment | 16 | ||
| Time | 16 | ||
| Employee Resistance | 16 | ||
| Regimentation | 17 | ||
| Security Gaps | 17 | ||
| ROLE OF THE HEALTHCARE PROFESSIONAL USING THE ELECTRONIC HEALTH RECORD | 18 | ||
| Duties and Workflow | 18 | ||
| Administrative | 18 | ||
| Clinical | 19 | ||
| Billing and Coding | 19 | ||
| PROFESSIONAL ORGANIZATIONS | 19 | ||
| American Health Information Management Association | 19 | ||
| American Academy of Professional Coders | 19 | ||
| American Association of Medical Assistants | 20 | ||
| American Medical Technologists | 20 | ||
| CHAPTER SUMMARY | 20 | ||
| CHAPTER REVIEW ACTIVITIES | 21 | ||
| 2 - Overview of SimChart for the Medical Office | 22 | ||
| THE MEDICAL PRACTICE GOES DIGITAL | 23 | ||
| ACCESSING SCMO THROUGH EVOLVE | 23 | ||
| GETTING COMFORTABLE WITH ELECTRONIC HEALTH RECORDS SOFTWARE | 24 | ||
| Resources for SCMO | 24 | ||
| SCMO ASSIGNMENT VIEW | 25 | ||
| MODULES | 26 | ||
| Front Office | 26 | ||
| Clinical Care | 26 | ||
| Coding & Billing | 27 | ||
| RECURRING FEATURES IN SCMO | 27 | ||
| Buttons | 27 | ||
| Default Settings | 28 | ||
| Info Panel | 28 | ||
| Structured and Unstructured Data Entry Options | 28 | ||
| Find Patient Tool | 28 | ||
| ESTABLISHING AND MAINTAINING A PATIENT REGISTRY | 28 | ||
| Enter a New Patient in SCMO | 29 | ||
| INTERNET USE IN THE MEDICAL OFFICE | 33 | ||
| Professional Use | 33 | ||
| Personal Use | 33 | ||
| CHAPTER SUMMARY | 33 | ||
| CHAPTER REVIEW ACTIVITIES | 34 | ||
| 3 - Privacy, Confidentiality, and Security | 41 | ||
| HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) | 42 | ||
| CONFIDENTIALITY VERSUS PRIVACY | 42 | ||
| Confidential Versus Anonymous | 43 | ||
| Privacy Rule | 44 | ||
| Covered Entities and Business Associates | 46 | ||
| Minimum Necessary Standard | 46 | ||
| Authorization Versus Consent | 47 | ||
| Security Rule | 47 | ||
| Privacy Versus Security | 47 | ||
| SECURITY SAFEGUARDS IN THE MEDICAL PRACTICE | 47 | ||
| Administrative Safeguards | 48 | ||
| Physical Safeguards | 48 | ||
| Login Procedures | 48 | ||
| Technical Safeguards | 49 | ||
| Assigning Employee Privileges | 49 | ||
| Designing Auditing Procedures | 49 | ||
| Limited-Access Policies for Specific Patients | 50 | ||
| PATIENTS’ RIGHTS UNDER HIPAA | 50 | ||
| OTHER SECURITY INITIATIVES | 52 | ||
| ACCESS TO PROTECTED HEALTH INFORMATION | 52 | ||
| Financial Institutions | 53 | ||
| Government Agencies | 53 | ||
| Consumer Reporting Agencies | 54 | ||
| Medical Information Bureau | 54 | ||
| Prescription Database Tools | 54 | ||
| Employers | 54 | ||
| Family and Friends | 55 | ||
| Internet Communities | 55 | ||
| Researchers | 55 | ||
| Direct Marketing Firms | 55 | ||
| HOW PATIENTS CAN PROTECT THEIR HEALTH INFORMATION | 55 | ||
| CHAPTER SUMMARY | 57 | ||
| CHAPTER REVIEW ACTIVITIES | 58 | ||
| 4 - Administrative Use of the Electronic Health Record Patient Letter | 60 | ||
| ROLE OF THE FRONT OFFICE ASSISTANT | 61 | ||
| COMMUNICATION IN THE MEDICAL OFFICE | 61 | ||
| Telephone Etiquette | 61 | ||
| Appointment Confirmation | 62 | ||
| Patient Correspondence | 64 | ||
| Physician Referral | 64 | ||
| Patient Letter | 65 | ||
| Secure Email | 66 | ||
| Faxing | 70 | ||
| INCIDENT REPORTS | 70 | ||
| MANAGING ELECTRONIC HEALTH RECORDS | 70 | ||
| Eliminating Duplicate Charts | 72 | ||
| Purging Patient Records | 72 | ||
| Integrated Devices | 72 | ||
| Backing Up the Electronic Health Record | 72 | ||
| CALENDAR | 73 | ||
| Calendar Views | 73 | ||
| Block an Appointment Time | 73 | ||
| Double-Booking | 77 | ||
| CHAPTER SUMMARY | 78 | ||
| CHAPTER REVIEW ACTIVITIES | 78 | ||
| 5 - Clinical Use of the Electronic Health Record | 80 | ||
| DOCUMENTATION IN THE ELECTRONIC HEALTH RECORD | 81 | ||
| Voice Recognition | 81 | ||
| Documenting Remote Patient-Provider Encounters | 82 | ||
| Telephone Documentation | 82 | ||
| E-Visits | 82 | ||
| CLINICAL DOCUMENTATION IN THE PATIENT RECORD | 83 | ||
| Patient Encounter | 83 | ||
| ALLERGIES | 84 | ||
| PATIENT HISTORY | 85 | ||
| MEDICAL AND SURGICAL HISTORY | 85 | ||
| CHIEF COMPLAINT | 87 | ||
| Pain Scale | 88 | ||
| MEDICATIONS | 89 | ||
| Vital Signs | 92 | ||
| Order Entry | 93 | ||
| Problem List | 94 | ||
| TRACKING HEALTH SCREENINGS AND IMMUNIZATIONS | 95 | ||
| USING THE ELECTRONIC HEALTH RECORD FOR PATIENT EDUCATION | 95 | ||
| THE PROGRESS NOTE | 96 | ||
| Digital Signature | 97 | ||
| CHAPTER SUMMARY | 97 | ||
| CHAPTER REVIEW ACTIVITIES | 98 | ||
| 6 - Using the Electronic Health Record for Reimbursement | 100 | ||
| HEALTHCARE REIMBURSEMENT | 101 | ||
| REVENUE CYCLE | 102 | ||
| CODING SYSTEMS | 103 | ||
| Role of the Electronic Health Record in Medical Coding | 103 | ||
| Coding and Claims Processing Errors | 103 | ||
| Current Procedural Terminology Coding (CPT) | 104 | ||
| Category I | 104 | ||
| Category II | 105 | ||
| Category III | 106 | ||
| Healthcare Common Procedure Coding System (HCPCS) | 106 | ||
| ICD-10-CM Coding | 106 | ||
| PAY FOR PERFORMANCE | 106 | ||
| Incentives and Penalties | 106 | ||
| Use of the Electronic Health Record in P4P Compliance | 107 | ||
| SUPERBILL | 107 | ||
| PATIENT LEDGER | 108 | ||
| HIPAA 5010 CLAIM PROCESSING | 110 | ||
| MEDICAL NECESSITY | 110 | ||
| FRAUD AND ABUSE | 112 | ||
| PATIENT STATEMENTS | 112 | ||
| REPORTING FEATURES OF AN EHR | 113 | ||
| CHAPTER SUMMARY | 114 | ||
| CHAPTER REVIEW ACTIVITIES | 114 | ||
| 7 - The Personal Health Record and Patient Portals | 116 | ||
| WHAT IS A PERSONAL HEALTH RECORD? | 117 | ||
| The Personal Health Record vs. the Medical Record | 117 | ||
| What Information Is Stored in a Personal Health Record? | 118 | ||
| Types of Personal Health Records | 118 | ||
| Paper-Based Personal Health Records | 119 | ||
| Personal Health Record Software | 119 | ||
| Online Personal Health Record | 120 | ||
| INNOVATIVE FEATURES OF PERSONAL HEALTH RECORDS | 120 | ||
| Synchronization with Medical Devices | 120 | ||
| ICE Notification | 120 | ||
| Drug Alerts | 121 | ||
| Limited Interoperability | 121 | ||
| Direct-to-Consumer Laboratory Services | 121 | ||
| Telephone Consults | 121 | ||
| Satellite and MP3 Technology | 121 | ||
| Why Create a Personal Health Record? | 121 | ||
| Benefits to Individuals, Patients, and Caregivers | 121 | ||
| Benefits to Providers | 122 | ||
| STEPS IN CREATING THE PERSONAL HEALTH RECORD | 122 | ||
| MAINTAINING THE PERSONAL HEALTH RECORD | 122 | ||
| PATIENT PORTALS | 124 | ||
| CHAPTER SUMMARY | 125 | ||
| CHAPTER REVIEW ACTIVITIES | 126 | ||
| A - Review of Paper-Based Office Procedures | 128 | ||
| PROGRESS NOTES | 133 | ||
| PROBLEM LIST | 135 | ||
| B - CMS Documentation Guidelines | 140 | ||
| GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATION | 140 | ||
| EVALUATION AND MANAGEMENT CODES | 140 | ||
| C - Front Office, Clinical Care, and Coding and Billing Application Exercises | 142 | ||
| FRONT OFFICE | 142 | ||
| SET UP APPOINTMENT MATRIX | 142 | ||
| SCHEDULING A NEW PATIENT APPOINTMENT | 142 | ||
| COMPLETING PATIENT DEMOGRAPHICS | 143 | ||
| UPDATING PATIENT DEMOGRAPHICS | 143 | ||
| DOCUMENT ALLERGIES | 143 | ||
| ENTER PATIENT HEALTH HISTORY | 144 | ||
| DOCUMENTING CHIEF COMPLAINT | 144 | ||
| DOCUMENTING MEDICATIONS | 145 | ||
| DOCUMENT VITAL SIGNS, HEIGHT, AND WEIGHT | 145 | ||
| COMPLETING A SUPERBILL | 145 | ||
| COMPLETING A PATIENT LEDGER | 146 | ||
| PREPARE A CLAIM | 146 | ||
| D - SimChart Supplement | 149 | ||
| GLOSSARY | 179 | ||
| Index | 182 | ||
| A | 182 | ||
| B | 182 | ||
| C | 182 | ||
| D | 182 | ||
| E | 183 | ||
| F | 183 | ||
| G | 183 | ||
| H | 183 | ||
| I | 183 | ||
| K | 183 | ||
| L | 183 | ||
| M | 184 | ||
| N | 184 | ||
| O | 184 | ||
| P | 184 | ||
| R | 184 | ||
| S | 184 | ||
| T | 185 | ||
| U | 185 | ||
| V | 185 | ||
| W | 185 |