COURSE NAME/NUMBER: Electronic Health Records MEDA 123
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COURSE NAME/NUMBER: Electronic Health Records MEDA 123 HOURS/CREDITS: 2 Credits CLASS LOCATION/TIMES: Building B, Room 125 Days: Monday, Wednesday, Friday Times: 10-11:20
PREREQUISITES: Successful completion of Front Office Procedures I-II MEDA 120-121 COURSE DESCRIPTION: This course is an introduction to the electronic medical records system, paperless charting and paperless scheduling. Students are provided with practical experience in data entry of patient information and generating insurance forms using a computerized billing program known as Spring charts. INSTRUCTOR: Lea Hoffman, CMA OFFICE HOURS/CONTACT INFORMATION: 7:30-8:00 a.m. and 2:30-3:00 p.m. (by appointment) Office Location: Building B, Room (425) 235-2352 Ext. 5734 Email: [email protected] COURSE OBJECTIVES (Course Competencies): Upon successful completion of this course the student will be able to: 1. Define electronic health records
2. Understand the core functions of an electronic health record as defined by the Institute of Medicine
3. Discuss social forces that are driving the adoption of electronic health records
4. Describe federal government strategies to promote electronic health record adoption
5. Explain why electronic health records are important
6. Describe the flow of medical information into the chart
7. Compare the workflow of an office using paper charts with an office using an electronic health record
8. Contrast inpatient and outpatient charts
9. Explain why patient visits should be documented at the point of care
Electronic Health Records 1 MEDA 123 Revised April 2013 10. Compare various types of electronic health record computers such as workstation, laptop, and Tablet PC
11. Compare different formats of EHR data
12. Describe the importance of codified EHR
13. Have an understanding of prominent EHR code sets such as SNOMED-CT, MEDCIN, LOINC, and CCC
14. Explain different methods of capturing and recording EHR data
15. Catalog and retrieve documents and images from a digital image system
16. Discuss the exchange of data between EHR and other systems
17. Discuss the benefits of patient-entered data
18. Describe the functional benefits from a codified EHR
19. Compare different formats of lab result data
20. Discuss alert systems and drug utilization review
21. Describe two important components of health maintenance
22. Provide examples of EHR decision support
23. Start and stop the Student Edition Software
24. Navigate the screen
25. Select a patient
26. Create a new encounter
27. Access the Symptoms, History, Physical Exam, Assessment, and Therapy tabs to add appropriate findings in each portion of the exam
28. Select findings for edit and remove findings
29. Add entry details, values, free text, results, status, and episodes to findings
30. Enter a chief complaint
31. Enter vital signs
32. Create a new encounter
33. Document a patient visit
34. Print a copy of the completed encounter note
Electronic Health Records 2 MEDA 123 Revised March 2012 35. Load and use Lists of Findings to speed up the data entry
36. Describe Review of Systems
37. Change Symptoms from History of Present Illness to Review of Systems
38. Know how to quickly record “pertinent negatives”
39. Understand and use Forms
40. Use Lists and Forms together
41. Discuss the importance of electronic orders and results
42. Compare paper and electronic workflow of orders and results
43. Search for a finding using the Search button
44. Understand and use the Prompt feature
45. Record orders for tests
46. Describe the workflow of radiology orders and reports
47. Use a CPOE to write a prescription
48. Discuss Closed Loop Safe Medication Administration
49. Name the five rights of medication administration
50. Order medication using a quick-pick list
51. Compare ICD-9-CM codes and ICD-10 codes
52. Use a diagnosis to find protocols
53. Order tests to confirm or rule out a diagnosis
54. Understand and use Patient Management
55. Understand and use Problem Lists
56. Cite information from previous visits in a new encounter
57. View pending orders
58. Review lab test results
59. Create a graph of lab results
60. Create a graph of vital signs in the chart
Electronic Health Records 3 MEDA 123 Revised March 2012 61. Describe flow sheets
62. Work with a flow sheet
63. Create a Form-based flow sheet
64. Create a Problem-based flow sheet
65. Use an EHR drawing tool to annotate drawings in an encounter
66. Document a well-baby checkup using a wellness form
67. Explain the relationship between vital signs and growth charts
68. Create a pediatric growth chart
69. Understand Body Mass Index
70. Calculate Body Mass Index
71. Understand immunization schedules
72. Order immunizations for a child
73. Describe how patients can be involved in their own health
74. Discuss preventive care guidelines
75. Understand how EHR preventive care systems work
76. List HIPAA transactions and uniform identifiers
77. Understand HIPAA privacy and security concepts
78. Apply HIPAA privacy policy in a medical facility
79. Discuss HIPAA security requirements and safeguards
80. Follow security policy guidelines in a medical facility
81. Explain electronic signatures
82. Discuss the effect of the impact of Internet Technology on healthcare
83. Explain how EHR systems use the internet
84. Describe support available on the web
85. Understand how the internet works
86. Discuss methods of remote access and secure Internet communications
Electronic Health Records 4 MEDA 123 Revised March 2012 87. Compare different types of telemedicine
88. Describe the advantages and workflow of patient-entered data
89. Contrast differences between provider-to-patient e-mail and secure messaging
90. Understand the workflow of the E-visit
91. Discuss patient success to electronic health records
92. Explain the criteria for Patient-Centered Medical Home
93. Understand and compare Personal Health Records
94. Explain why billing codes are important in an EHR system
95. Show how Evaluation and Management (E&M) codes are determines
96. Name and describe key components of E&M codes
97. Read and understand the tables used in CMS guidelines
98. Explain how the level of key components determines the level of E&M codes
99. Use E&M calculator software
100. Correctly use and document the time factor to change the level of an E&M code
ATTENDANCE AND MAKE-UP POLICY: Throughout the Medical Assistant Program, an outstanding work ethic is emphasized and encouraged. Participation and professionalism are essential to your success as a student and as a Medical Assistant. Ten percent of your grade involves participation and professionalism. Professionalism points will be deducted at a total of 1 point per 60 minutes of class time missed for each subject. Point deductions will be broken down in 15 minute increments. For example: 0- 15 minutes = 0.25 points, 16 -30 minutes = 0.50 minutes, etc.
If you must be absent, make arrangements beforehand to have a fellow student obtain any handouts and reading assignments you miss. You are also responsible for getting assignments from a fellow student by phone or email when you are absent in order to complete an assignment on time. Students missing three (3) or more consecutive class days due to illness are required to submit a note from their healthcare provider certifying they are physically able to return to the classroom. The full attendance policy is outlined in your medical assistant packet.
NATURE OF THE COURSE: To accommodate a wide variety of learning and personal styles many different instructional approaches may be used including: lecture, group discussion, demonstrations, interactive exercises, role playing, video programs, computer based training, student research, self directed learning projects and collaborative teaching with Program Instructors.
Electronic Health Records 5 MEDA 123 Revised March 2012 COURSE OUTLINE: See attached document
GRADING: Grades are based on the following weighted categories and assigned the corresponding decimal grade: Professionalism/Participation 15% Homework 10% Quizzes 20% Mid Term/Paper 25% Final Exam 30%
TEXT: Neehr Perfect subscription
EMERGENCY INSTRUCTIONS FOR INCLEMENT WEATHER: In case of weather closure of the RTC Campus, class will be cancelled. Call the school at (425) 235-2352 and choose option 9 for weather closure information. Information will also be available on the website (www.RTC.edu) and local television and radio stations. CLASSROOM MANAGEMENT POLICIES: Renton Technical College recognizes and values diversity between students on campus, including cultural diversity, diversity of age, life style, race, religion, and financial backgrounds. Students are expected to listen respectfully to others and conduct themselves professionally in the classroom, at clinical sites, and at all campus related activities. Certain behaviors will not be tolerated. Students engaging in those behaviors will be asked to leave the classroom and appropriate disciplinary steps will be taken. Students will also lose all their professionalism points for the day. Examples are:
Unprofessional or disruptive behavior Sleeping in class Inappropriate attire Foul language Sexual harassment Cheating and Plagiarism: As outlined in the Allied Health Department Handbook, Renton Technical College has a zero tolerance policy towards cheating and plagiarism. On a paper or presentation, if wording is taken directly from any source without giving credit to the source, the student will receive a zero (0) on that paper or presentation. When there is doubt, the instructor will make the final judgment on whether plagiarism has occurred.
Electronic Health Records 6 MEDA 123 Revised March 2012 Cheating occurs on a quiz, mid-term or final the student will not receive credit and will be subject to disciplinary action. Disciplinary action includes, but is not limited to, the student receiving a zero (0) on a test, paper or presentation up to and including immediate expulsion from the program. Reading Assignments: The student is responsible for reading all assigned material prior to the lecture. Much more can be gained from the classroom discussion if there is some basic familiarity with the content. Quizzes: There will be quizzes given approximately once a week. A Pop Quiz could be given at any point when the instructor needs to evaluate how much information is being assimilated by the students. Pop Quizzes cannot be made up. The first time an absence occurs 10% of the total possible points will be deducted from the quiz; the second absence 30% will be deducted and the third absence 50% will be deducted from the quiz. Students will not receive credit for a pop quiz if they are absent. The student must make arrangements with the instructor outside of class time to make up a quiz. Arriving more than 10 minutes late for a quiz will be considered an absence. Mid Term and Final: There will be a mid-term given after which the student and instructor will meet and discuss progress as necessary. A final exam will be given during the last week of the quarter. You will lose one letter grade for every day the final examination is not taken from the date it is offered to the rest of the class. The mid-term and cumulative final will be proctored and may be administered in any form (written, oral, online, etc.). Homework: is due on the assigned date and must be complete to earn homework points. If a student is absent on the day homework is due the homework is considered late and must be submitted the day the student returns to school to earn points, unless a copy of the homework is submitted via email before class starts. Points are earned as follows:
Submitted on time and complete 10 points
Submitted late and complete 5 points
Note: Information contained in this syllabus is subject to change
Electronic Health Records 7 MEDA 123 Revised March 2012 Decimal Grade Letter Grade Percent Grade Equivalent 4.0 100 A 3.9 99 3.8 98 A- 3.7 97 3.6 96 3.5 95 3.4 94 B+ 3.3 93 3.2 92 3.1 91 B 3.0 90 2.9 89 2.8 88 B- 2.7 87 2.6 86 2.5 85 2.4 84 C+ 2.3 83 2.2 82 2.1 81 C 2.0 80 1.9 79 C- 1.8 78 1.7 77 1.6 76 1.5 75 1.4 74 D+ 1.3 73 1.2 72 1.1 71 D 1.0 70 0.9 69 D- 0.8 68 0.7 67 0.0 66 or less F
Note: Students must earn at least a grade or 2.0 (80%) in each course to continue in the Medical Assistant Program.
Electronic Health Records 8 MEDA 123 Revised March 2012