Lecture Electronic health records for allied health careers: Chapter 7 - Susan Sanderson

Chapter 7 - Introduction to practice partner. After studying this chapter, you should be able to: Explain how the use of access levels protects the privacy of information in a patient record, describe the purpose of the dashboard, explain where patient registration information is stored and accessed, explain the function of the Chart Summary,...

Cover goes here when ready Electronic Health Records for Allied Health Careers Chapter Introduction to Practice Partner McGraw­Hill Copyright © 2009 by The McGraw­Hill Companies, Inc. All Rights Reserved 7-2 Learning Outcomes After studying this chapter, you should be able to: Explain how the use of access levels protects the privacy of information in a patient record Describe the purpose of the dashboard Explain where patient registration information is stored and accessed Explain the function of the Chart Summary Describe how progress notes can be entered Explain how Practice Partner assists with coding a patient encounter 7-3 Learning Outcomes After studying this chapter, you should be able to: List two safety and cost-control features of electronic order entry Discuss the medication list in Practice Partner Explain how Practice Partner displays abnormal values in vital signs and lab results 10 Describe how the HIPAA section of the patient chart can be used to document HIPAA compliance 7-4 Key Terms • access levels • Dashboard • evaluation and management codes (E/M codes) • Lookup • progress notes • SOAP • Web View 7-5 What is Practice Partner? • Practice Partner is an electronic health record and practice management program for ambulatory practices 7-6 Passwords • Users must have a user ID, password, and access level to log in 7-7 Access Levels • restrict access to only the information the user needs to fulfill their responsibilities 7-8 Park Feature • Allows user to leave workstation without exiting the program 7-9 Practice Partner Main Window 7-10 Practice Partner Main Window • Main window contains: – Title bar – Menu bar – Toolbar – Status bar 7-14 Chart • Organized by folders, similar to a paper chart 7-15 Chart: Chart Summary • Overview of most recent clinical information 7-16 Chart: Progress Notes • Records of a patient’s visits 7-17 Evaluation & Management Coding • Analyzes the progress note and suggests the appropriate E/M code 7-18 Chart: Medical History • Past Medical History • Social History • Family History 7-19 Chart: Orders • Computerized physician order entry (CPOE) 7-20 Chart: Problem List • Contains all problems for which patient has sought treatment: – – – – – – Major Problems Other Problems Procedures Diagnoses Risks Hospitalizations 7-21 Chart: Health Maintenance • Tracks periodic preventive tests and examinations 7-22 Chart: Rx/Medications • Organizes and maintains medications 7-23 Chart: Rx/Medications • Medication safety features: – – – – Drug Interaction and Allergy Checking Drug Dosage Checking Diagnosis Checking Formulary Checking 7-24 Chart: Vital Signs • Entered manually or from a digital monitor 7-25 Patient Education • Built-in patient education articles 7-26 Chart: Laboratory Data • Entered manually or imported electronically 7-27 Chart: Images • Can be annotated and added to progress notes, etc 7-28 Chart: HIPAA • Used for HIPAArelated documents ... clinical information 7- 13 Lookup Function • Provides various search options for obtaining more information about a patient  7- 14 Chart • Organized by folders, similar to a paper chart  7- 15 Chart:... clinical information 7- 16 Chart: Progress Notes • Records of a patient’s visits 7- 17 Evaluation & Management Coding • Analyzes the progress note and suggests the appropriate E/M code  7- 18 Chart:... Diagnosis Checking Formulary Checking 7- 24 Chart: Vital Signs • Entered manually or from a digital monitor  7- 25 Patient Education • Built-in patient education articles  7- 26 Chart: Laboratory