DEPARTMENT/COURSE



COURSE NAME/NUMBER: Electronic Health Records MEDA 123

HOURS/CREDITS: 2 Credits

CLASS LOCATION/TIMES: Building B, Room 125

Days: Thursday

Times: 7:30-9:00 a.m.

PREREQUISITES: Successful completion of

Front Office Procedures I-III MEDA 120-122

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: Sheila O’Connor

OFFICE HOURS/CONTACT INFORMATION: 7

Office Hours: (by appointment)

Office Location: Building B, Room 125

(425) 235-2352 Ext. 5734

Email: soconnor@rtc.edu

COURSE OBJECTIVES (Course Competencies): Upon successful completion of this course the student will be able to:

1. EHR Objectives

2. Define electronic records.

3. Understand the core functions of an electronic health record as defined by the Institute of Medicine.

4. Discuss social forces that driving the adoption of electronic health records.

5. Define federal government strategies to promote electronic health record adoption.

6. Explain why electronic health records are important.

7. Scribe the flow of medical information into the chart.

8. Compare the workflow of an office using paper charts with an office using an electronic health record.

9. Contrast inpatient and outpatient charts.

10. Explain why patient visits should be documented at the point of care.

11. Compare various types of electronic health record computers such as workstation, laptop, and Tablet PC.

12. Compare different formats of EHR data.

13. Describe the importance of codified EHR.

14. Have an understanding of prominent EHR code sets.

15. Explain different methods of capturing and recording EHR data.

16. Catalogue and retrieve documents and images from a digital image system.

17. Discuss the exchange of data between EHR and other systems.

18. Discuss the benefits of patient entered data.

19. Describe the functional benefits of codified EHR.

20. Compare different formats of lab result data.

21. Discuss alert systems and utilization review.

22. Describe two important components of health maintenance.

23. Provide examples of EHR decision support.

24. Start and stop the student edition software.

25. Navigate the screen.

26. Select a patient.

27. Create a new encounter.

28. Access various tabs to add appropriate findings.

29. Select findings for and removal.

30. Add entry details, values, free text, results, status, and episodes to findings.

31. Enter a chief complaint.

32. Enter vital signs.

33. Create a new encounter.

34. Document a patient visit.

35. Print a copy of the completed encounter form.

36. Load and use “List of Findings” to speed up data entry.

37. Describe Review of Systems.

38. Change symptoms from History of Present Illness to Review of Systems.

39. Know how to quickly record “pertinent negatives”.

40. Understand the use of Forms.

41. Use Lists and Forms together.

42. Discuss the importance of electronic orders and results.

43. Compare paper and electronic workflow of orders and results.

44. Search for a finding using the Search button.

45. Understand and use the Prompt feature.

46. Record orders for tests.

47. Describe the workflow of radiology orders and reports.

48. Use a CPOE to write a prescription.

49. Discuss Closed Loop Safe Medication Administration.

50. Name the five rights of medication administration.

51. Order medications using a quick-pick list.

52. Compare ICD-9-CM codes and ICD-10codes.

53. Use a diagnosis to find a protocol.

54. Order tests to confirm or rule out a diagnosis.

55. Understand and use Patient Management and the Problems 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 test results and a graph of vital sign in the chart.

60. Describe flow sheets.

61. Work with flow sheets.

62. Create a Form-based and a Problem-based flow sheet.

63. Use an EHR drawing tool to annotate drawings in an encounter.

64. Document a well-baby checkup using a wellness form.

65. Explain the relationship between vital signs and growth charts.

66. Create a pediatric growth chart.

67. Understand the Body Mass Index.

68. Calculate body Mass Index.

69. Understand the immunization schedule.

70. Order immunizations for a child.

71. Describe how patients can be involved in their own health.

72. Discuss preventative care guidelines.

73. Understand how EHR preventive care systems work.

74. Discuss the effect of the impact of internet technology on healthcare.

75. Explain how EHR systems use the internet.

76. Describe decision support available on the web.

77. Understand how the internet works.

78. Discuss methods of remote access and secure internet communications.

79. Compare different types of telemedicine.

80. Describe the advantages and workflow of patient-entered-data.

81. Contrast differences between provider-to-patient e-mail and secure messaging.

82. Understand the workflow of an e-visit.

83. Discuss patient access to electronic health records.

84. Explain the criteria for Patient-Centered Medical Home.

85. Understand and compare Personal Health Records.

86. Explain why billing codes are important to an EHR system.

87. Show how an Evaluation & Management (E&M) codes are determined.

88. Name and describe key components of E&M codes.

89. Read and understand the tables used in CMS guidelines.

90. Explain how the level of key components determines the level of E&M code.

91. Use the E&M code calculator software.

92. 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.

COURSE OUTLINE: See attached document

GRADING: Grades are based on the following weighted categories and assigned the corresponding decimal grade:

Professionalism/Participation 10%

Homework 20%

Quizzes 30%

Final Exam 40%

TEXT: Gartee, Richard. Electronic Health Records: Understanding and Using Computerized Medical Records, 2nd Edition, Upper Saddle River, New Jersey: Pearson Prentice Hall, 2011.

My Health Professional Kit Student Access Kit

ADDITIONAL MATERIALS:

Pens: Blue or black ink; no erasable or gel pens

USB Drive to store work

RESOURCES:



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 (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.

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.

Questions: If you do not understand something during a lecture and do not want to ask a question in front of the entire class, talk to your instructor or other students when there is free time within the classroom. (There will be frequent opportunities at the end of class sessions to get clarification) Asking classmates questions while other classroom information is taking place is disruptive to the entire class and the instructor. It also causes students to miss what is currently being discussed.

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. If you are absent on the day of a scheduled quiz, you must make up the quiz the day you return to school to receive credit. In addition, if you are more than 10 minutes late for a quiz you will need to make it up by arrangement with the instructor. The highest possible grade for a make-up quiz is 90%.

NOTE: If your class is a hybrid quizzes will be administered on line. These quizzes will be timed and available on specified days as noted in the course outline. Quizzes not taken during the available time frame can only be made up at the discretion of the instructor. DO NOT wait until the last minute to take your quizzes.

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. Incomplete homework must be submitted within one school day of the due date to receive 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 earn points. 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.

Allied Health Grading Scale 2011

|Decimal Grade |Grade Percent |Letter 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.

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