| About the Authors |
|
v | |
| Acknowledgments |
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vi | |
| Thank You |
|
vii | |
| Preface |
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ix | |
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Chapter 1 Electronic Health Records---An Overview |
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1 | (30) |
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Evolution of Electronic Health Records |
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2 | (2) |
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Institute of Medicine (IOM) |
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2 | (2) |
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Computer-based Patient Record Institute (CPRI) |
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4 | (1) |
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Health Insurance Portability and Accountability Act (HIPAA) |
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4 | (1) |
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4 | (1) |
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Social Forces Driving EHR Adoption |
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4 | (2) |
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4 | (1) |
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5 | (1) |
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5 | (1) |
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Critical Thinking Exercise 1: EHR News |
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6 | (1) |
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6 | (3) |
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Office of National Coordinator for Health Information Technology |
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6 | (1) |
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6 | (1) |
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Federal Health IT Strategic Plan 2008-2012 |
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7 | (1) |
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8 | (1) |
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Critical Thinking Exercise 2: Compare ONC and HITECH |
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8 | (1) |
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Strategic Plan Update 2011 -2015 |
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8 | (1) |
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Meaningful Use of a Certified EHR |
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9 | (3) |
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9 | (2) |
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11 | (1) |
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Clinical Quality Measures (CQM) |
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12 | (1) |
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Why Electronic Health Records Are Important |
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12 | (2) |
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Critical Thinking Exercise 3: When the Chart Is Lacking |
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12 | (1) |
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Real-Life Story: Where's My Chart? |
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13 | (1) |
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Flow of Clinical Information into the Chart |
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14 | (5) |
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Workflow of an Office Using Paper Charts |
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15 | (2) |
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Workflow of an Office Fully Using an EHR |
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17 | (1) |
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Critical Thinking Exercise 4: Think About Workflow |
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18 | (1) |
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Inpatient Charts versus Outpatient Charts |
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19 | (3) |
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Documenting at the Point of Care |
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22 | (6) |
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The Physical Clinic and Clinician Mobility |
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24 | (1) |
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EHR on Computer Workstations |
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25 | (1) |
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26 | (1) |
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27 | (1) |
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27 | (1) |
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28 | (3) |
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Chapter 2 Functional EHR Systems |
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31 | (39) |
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Format of Data Determines Potential Benefits |
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32 | (1) |
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32 | (1) |
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Limitations of Certain Types of Data |
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32 | (1) |
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Standard EHR Coding Systems |
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33 | (9) |
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34 | (1) |
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34 | (1) |
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35 | (1) |
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35 | (1) |
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36 | (2) |
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38 | (1) |
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38 | (1) |
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38 | (1) |
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Clinical Care Classification System (CCC) |
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38 | (1) |
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39 | (1) |
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39 | (1) |
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39 | (1) |
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39 | (1) |
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40 | (1) |
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40 | (1) |
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40 | (1) |
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Real-Life Story: A Nurse's Experiences with Development of Health Data Standards |
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41 | (1) |
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Capturing and Recording EHR Data |
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42 | (16) |
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42 | (1) |
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Guided Exercise 5: Exploring a Document Imaging System |
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42 | (1) |
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The Document/Image System Window |
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42 | (5) |
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47 | (2) |
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Guided Exercise 6: Importing and Cataloging Images |
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49 | (5) |
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Picture Archival and Communication System (PAC) |
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54 | (1) |
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Importing Text to the EHR |
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54 | (1) |
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55 | (1) |
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55 | (1) |
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56 | (1) |
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56 | (1) |
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56 | (1) |
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57 | (1) |
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57 | (1) |
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58 | (1) |
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58 | (1) |
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Functional Benefits from Codified Records |
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58 | (9) |
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58 | (1) |
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Critical Thinking Exercise 7: Retrieving a Scanned Lab Report |
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59 | (1) |
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59 | (1) |
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60 | (1) |
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61 | (1) |
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62 | (1) |
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Nursing Medications Alerts |
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63 | (1) |
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63 | (2) |
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65 | (1) |
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65 | (1) |
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65 | (1) |
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65 | (1) |
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66 | (1) |
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Meeting the IOM Definition of an EHR |
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67 | (1) |
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67 | (3) |
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Chapter 3 Learning Medical Record Software |
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70 | (37) |
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Introducing the Medcin Student Edition Software |
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71 | (1) |
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About the Exercises in This Book |
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71 | (1) |
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71 | (1) |
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Critical Thinking Exercise 8: Electronic Signature |
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72 | (1) |
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Understanding the Software |
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72 | (2) |
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Guided Exercise 9: Starting Up the Software |
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72 | (2) |
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74 | (7) |
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Guided Exercise 10: Exiting and Restarting the Software |
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75 | (1) |
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Guided Exercise 11: Using the Menu to Select a Patient |
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76 | (2) |
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Guided Exercise 12: Navigating the Medcin Findings |
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78 | (2) |
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Guided Exercise 13: Tabs on the Medcin Nomenclature Pane |
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80 | (1) |
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Data Entry of Clinical Notes |
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81 | (9) |
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Guided Exercise 14: Creating an Encounter |
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81 | (2) |
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Guided Exercise 15: Recording the Admitting Diagnosis |
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83 | (2) |
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Guided Exercise 16: Recording Subjective Findings |
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85 | (1) |
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Guided Exercise 17: Removing Findings |
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86 | (2) |
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Guided Exercise 18: Recording More Specific Findings |
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88 | (1) |
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Guided Exercise 19: Recording History Findings |
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89 | (1) |
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Adding Details to the Findings |
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90 | (4) |
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Guided Exercise 20: Recording a Value |
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91 | (1) |
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Guided Exercise 21: Recording Objective Findings |
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91 | (2) |
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Guided Exercise 22: Adding Detail to Recorded Findings |
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93 | (1) |
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94 | (6) |
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Guided Exercise 23: Adding Free Text |
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94 | (1) |
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Guided Exercise 24: Using the Tx Tab and Setting the Prefix Field |
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95 | (1) |
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Guided Exercise 25: Using the Free-Text Finding Note Window |
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96 | (2) |
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Guided Exercise 26: Recording Nursing Care on the Rx Tab |
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98 | (2) |
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Introduction to Using Forms |
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100 | (4) |
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Guided Exercise 27: Recording the Chief Complaint |
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100 | (1) |
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Guided Exercise 28: Recording Vital Signs |
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100 | (3) |
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Real-Life Story: Overcoming Fear of the EHR |
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103 | (1) |
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Visually Different Button Styles |
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103 | (1) |
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104 | (3) |
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Chapter 4 Increased Familiarity with the Software |
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107 | (37) |
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108 | (1) |
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Creating Your First Complete Encounter Note |
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108 | (14) |
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Guided Exercise 29: Documenting an Admit for DVT |
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108 | (9) |
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Guided Exercise 30: Printing the Encounter Note |
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117 | (5) |
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Invoking the Print Dialog Window from the Toolbar |
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122 | (1) |
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Creating an Initial Chart Upon Admission |
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122 | (20) |
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Guided Exercise 31: Documenting an Admit for Transien t Ischemic A ttack (TIA) |
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122 | (13) |
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Real-Life Story: A Nurse's Notes |
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135 | (1) |
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Critical Thinking Exercise 32: Documenting an Admit for the Cath Lab |
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136 | (6) |
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142 | (2) |
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Chapter 5 Data Entry at the Point of Care |
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144 | (44) |
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Why Speed of Entry is Important in the EHR |
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145 | (1) |
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Lists and Forms Speed Data Entry |
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145 | (1) |
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Shortcuts That Speed Documentation of Typical Cases |
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145 | (1) |
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146 | (18) |
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Guided Exercise 33: Using an Adult URI List |
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146 | (13) |
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Critical Thinking Exercise 34: Using a Syncope List for a TIA Case |
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159 | (5) |
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164 | (1) |
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Comparison of Lists and Forms |
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164 | (1) |
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Initial Intake Form for an Adult |
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164 | (13) |
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Guided Exercise 35: Using Forms |
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166 | (11) |
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177 | (8) |
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Real-Life Story: How Forms Help Nurses in a Busy Pedia trie Practice |
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179 | (1) |
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Critical Thinking Exercise 36: Using a Form and a List |
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179 | (6) |
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185 | (3) |
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Chapter 6 Electronic Nursing Care Plans |
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188 | (60) |
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189 | (1) |
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Bringing the EHR to Nursing |
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189 | (1) |
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190 | (6) |
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Guided Exercise 37: Reviewing a Nursing Plan of Care |
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192 | (4) |
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Effectiveness of EHR Nursing Plans of Care Using CCC |
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196 | (1) |
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Standard Nursing Plans of Care |
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196 | (6) |
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196 | (1) |
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Guided Exercise 38: Comparing Care Pathway and EHR Plan of Care |
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197 | (4) |
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Real-Life Story: Creating Care Plans the Hard Way |
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201 | (1) |
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Individualized Plans of Care |
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202 | (14) |
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Guided Exercise 39: Creating an Individualized Nursing Plan of Care |
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202 | (1) |
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Part 1 Document the RN Assessment |
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202 | (4) |
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Part 2 Document the Nursing Diagnosis |
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206 | (2) |
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Part 3 Identify the Expected Outcomes |
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208 | (1) |
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209 | (7) |
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216 | (1) |
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The Interactive Nursing Plan of Care |
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217 | (9) |
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Guided Exercise 40: Using an Interactive Nursing Plan of Care |
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217 | (5) |
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222 | (1) |
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223 | (3) |
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226 | (12) |
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Guided Exercise 41: Reviewing an Inpatient Chart |
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230 | (2) |
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Critical Thinking Exercise 42: Nursing Plan of Care for an Inpatient with Atrial Fibrillation |
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232 | (6) |
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238 | (2) |
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Comprehensive Evaluation of
Chapters 1-6 |
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240 | (1) |
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240 | (1) |
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Part II Online Student Exercise Questions |
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241 | (1) |
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Part III Hands-On Exercise |
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241 | (7) |
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Critical Thinking Exercise 43: Admission of an Inpatient with Asthma |
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241 | (7) |
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Chapter 7 Understanding Electronic Orders |
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248 | (53) |
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The Importance of Electronic Orders and Results |
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249 | (1) |
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Recording Orders in the Student Edition |
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249 | (1) |
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250 | (3) |
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Comparison of Orders and Results Workflows |
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253 | (3) |
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Workflow of Paper Lab Orders and Results |
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254 | (1) |
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Workflow of Electronic Lab Orders and Results |
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254 | (2) |
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Learning to Use the Search and Prompt Features |
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256 | (10) |
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257 | (1) |
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Guided Exercise 44: Using Search and Prompt |
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257 | (6) |
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Guided Exercise 45: Ordering Diagnostic Tests |
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263 | (3) |
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Radiology Orders and Reports |
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266 | (4) |
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Critical Thinking Exercise 46: Ordering an X-Ray |
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267 | (3) |
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270 | (10) |
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270 | (1) |
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271 | (1) |
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Closing the Loop on Safe Medication Administration |
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271 | (2) |
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Guided Exercise 47: Writing Prescriptions in an EHR |
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273 | (7) |
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Quick Access to Frequent Orders |
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280 | (4) |
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Critical Thinking Exercise 48: Ordering Medications Using a Quick-Pick List |
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280 | (3) |
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Real-Life Story: When Orders and Results Are Critical |
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283 | (1) |
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Protocols Based on Diagnosis Codes |
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284 | (4) |
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Introducing Diagnosis Codes |
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285 | (1) |
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285 | (1) |
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Future Developments: ICD-10 |
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286 | (1) |
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ICD-9-CM and EHR Nomenclatures |
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287 | (1) |
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Primary and Secondary Diagnoses |
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287 | (1) |
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287 | (1) |
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288 | (1) |
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Using Diagnosis to Find Orders and Treatments |
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288 | (10) |
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Guided Exercise 49: Orders Based on Diagnosis |
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288 | (5) |
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Guided Exercise 50: Multiple Diagnoses |
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293 | (5) |
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298 | (3) |
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Chapter 8 Problem Lists, Results Management, and Trending |
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301 | (36) |
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Longitudinal Records to Manage Clients' Health |
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302 | (1) |
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Understanding Problem Lists |
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303 | (5) |
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Guided Exercise 51: Exploring the Manage Tab |
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303 | (5) |
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Citing Previous Visits from Problem Lists |
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308 | (9) |
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Guided Exercises 52: Following Up on a Problem |
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309 | (8) |
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Orders and Results Management |
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317 | (10) |
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Guided Exercise 53: Viewing Pending Orders and Lab Results |
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317 | (9) |
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Real-Life Story; A Nurse Practitioner Talks about Her Profession |
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326 | (1) |
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327 | (6) |
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Using Graphs to View Trends of Lab Results |
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327 | (1) |
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Guided Exercise 54: Graphing Lab Results |
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327 | (4) |
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Guided Exercise 55: Graphing Vital Signs in the Chart |
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331 | (2) |
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Visual Aides to Engage Clients in Their Own Healthcare |
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333 | (1) |
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Critical Thinking Exercise 56: Graphing Total Cholesterol and Weight |
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333 | (1) |
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334 | (3) |
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Chapter 9 Data Entry Using Flow Sheets and Anatomical Drawings |
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337 | (49) |
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Learning to Use Flow Sheets |
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338 | (29) |
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Guided Exercise 57: Working with a Flow Sheet |
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338 | (3) |
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About the Flow Sheet View |
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341 | (12) |
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Guided Exercise 58: Creating a Problem-Oriented Flowsheet |
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353 | (2) |
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Guided Exercise 59: Creating a Flow Sheet from a Nursing Care Plan |
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355 | (12) |
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Real-Life Story: Nurse Who Uses Flow Sheets and Trending |
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367 | (1) |
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Use of Anatomical Drawings in the EHR |
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367 | (1) |
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Navigation by Body System |
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367 | (1) |
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Annotated Drawings as EHR Data |
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368 | (16) |
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Guided Exercise 60: Annotated Dermatology Exam |
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368 | (10) |
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Critical Thinking Exercise 61: Examination of a Client with Pressure Sores |
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378 | (6) |
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384 | (2) |
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Chapter 10 Subacute Care, Nursing Homes, and Home Care |
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386 | (41) |
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Postdischarge Nursing Care |
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387 | (1) |
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Long-Term Care Facilities |
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387 | (1) |
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Long-Term Acute Care Facilities |
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387 | (1) |
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Rehabilitation Facilities |
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387 | (1) |
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Skilled Nursing Facilities |
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388 | (1) |
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Residential Care Facilities |
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388 | (1) |
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388 | (1) |
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388 | (1) |
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388 | (1) |
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389 | (1) |
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Resident Assessment Instrument |
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390 | (20) |
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Content of the RAI for Nursing Homes |
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390 | (1) |
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Guided Exercise 62: Studying the MDS 3.0 RAI |
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391 | (10) |
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Guided Exercise 63: Assessing Functional Status |
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401 | (8) |
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Real-Life Story: A Nurse's Experiences with MDS in Nursing Homes |
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409 | (1) |
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410 | (1) |
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411 | (1) |
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411 | (7) |
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Critical Thinking Exercise 64: OASIS-C Form for Head Injury with Residual Dementia |
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413 | (5) |
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418 | (6) |
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Guided Exercise 65: Comparing Home Care Planning Data |
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418 | (6) |
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424 | (3) |
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Chapter 11 Using the Internet to Expedite Care |
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427 | (37) |
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428 | (1) |
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429 | (2) |
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Critical Thinking Exercise 66: Internet Search for Client Education Materials |
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430 | (1) |
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Decision Support Via the Web |
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431 | (2) |
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Critical Thinking Exercise 67: Internet Nursing Research |
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432 | (1) |
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Integrating Decision Support |
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433 | (1) |
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Understanding the Internet |
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433 | (2) |
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434 | (1) |
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434 | (1) |
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Practicing Medicine Online |
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435 | (1) |
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436 | (2) |
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436 | (1) |
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Asynchronous Telemedicine at Mayo Clinic |
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437 | (1) |
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437 | (1) |
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Entry of Symptoms and History by the Client |
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438 | (10) |
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Workflow Using Client-Entered Data |
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439 | (1) |
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440 | (1) |
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Improved Client Information |
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440 | (1) |
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Guided Exercise 68: Experiencing Client-Entered HPI |
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441 | (6) |
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Critical Thinking Exercise 69: Reviewing Client-Entered Data |
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447 | (1) |
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Provider-to-Patient E-Mail Communication |
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448 | (2) |
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448 | (1) |
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Real-Life Story: Using the Internet to Build a Client-Centered Practice |
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449 | (1) |
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450 | (11) |
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451 | (1) |
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Mayo Clinic Study of E-Visits |
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452 | (1) |
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452 | (1) |
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Guided Exercise 70: Client Requests an E-Visit |
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453 | (4) |
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Guided Exercise 71: Clinician Completes the E-Visit |
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457 | (4) |
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461 | (3) |
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Chapter 12 Using the EHR for Prevention and Health Maintenance |
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464 | (41) |
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Prevention and Early Detection |
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465 | (1) |
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Pediatric Wellness Visits |
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465 | (10) |
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Guided Exercise 72: A Well-Baby Checkup |
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465 | (10) |
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Understanding Growth Charts |
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475 | (4) |
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476 | (1) |
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Guided Exercise 73: Creating a Growth Chart |
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476 | (3) |
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479 | (2) |
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Guided Exercise 74: Graphing BMI |
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479 | (1) |
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Critical Thinking Exercise 75: Adult BMI Categories |
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480 | (1) |
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The Importance of Childhood Immunizations |
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481 | (6) |
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Guided Exercise 76: Reviewing and Ordering Vaccines |
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|
481 | (1) |
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Immunization Schedules from the CDC |
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482 | (5) |
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Critical Thinking Exercise 77: Determine Your Adult Immunizations |
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|
487 | (1) |
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Client Involvement in Their Own Healthcare |
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487 | (1) |
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Client-Entered Data Graphs |
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487 | (1) |
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Preventative Care Screening |
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488 | (2) |
|
Real-Life Story: First Patient Whose Life Was Saved by Expert System Software He Operated Himself |
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489 | (1) |
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Client Access to Electronic Health Records |
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490 | (1) |
|
The Patient-Centered Medical Home |
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|
490 | (1) |
|
The Personal History Record |
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|
491 | (2) |
|
Critical Thinking Exercise 78: Researching the PHR |
|
|
492 | (1) |
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|
|
493 | (2) |
|
Comprehensive Evaluation of
Chapters 7-12 |
|
|
495 | (1) |
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|
|
495 | (1) |
|
Part II Hands-On Exercise |
|
|
496 | (7) |
|
Critical Thinking Exercise 79: Examination of a Client with Arterial Disease |
|
|
496 | (7) |
|
Part III Internet Exercise |
|
|
503 | (2) |
|
Critical Thinking Exercise 80: Nurse Teaches Client How to Research Medication |
|
|
503 | (2) |
| Glossary |
|
505 | (13) |
| Index |
|
518 | |
