Health Information Documentation

HTH 2305, Health Information Documentation Management 1

Course Learning Outcomes for Unit II Upon completion of this unit, students should be able to:

1. Utilize medical practice management software used in data entry. 1.1 Use student edition software to document a sample patient encounter. 1.2 Discuss the strengths and limitations of different health information exchange organizations and

methods.

3. Discuss the legal restrictions pertaining to software copyright laws and license agreements. 3.1 Differentiate between two proprietary EHR software. 3.2 Discuss the ownership of patient data.

5. Describe proper billing codes for different medical divisions.

5.1 Explain ICD-10CM and CPT-4.

Course/Unit Learning Outcomes

Learning Activity

1.1 Unit lesson; Chapter 2; Reflection Paper

1.2 Unit lesson; Chapter 2; Reflection Paper

3.1 Unit lesson; Chapter 2; Reflection Paper

3.2 Unit lesson; Chapter 2; Reflection Paper

5.1 Unit lesson; Chapter 2; Reflection Paper

Reading Assignment Chapter 2: Functional EHR Systems

Unit Lesson Having the capacity to locate, distribute, and explore a patient’s medical record are just three advantages of an electronic health record (EHR) over a paper record system (Gartee, 2017). The Institute of Medicine (IOM) recognized four functional advantages that are decision support, alerts, trend analysis, and health maintenance. Just imagine how wonderful it would be if the emergency department could retrieve your medical records from your primary and specialist physicians or if the pharmacy would receive alerts if different physicians prescribe you medication that will have contraindications. The EHR contains three formats in which data can be stored. The formats are digital images, text files, and discrete data. Digital images are electronically scanned forms and diagnostic images like X-rays, pathology, and CAD drawings. Digital images allow patients to get a copy of the diagnostic test performed and take it to the specialist after the radiologist has reviewed and dictated the examination. Text files allow a facility to scan an outside report into its EHR system. Text files offer an advantage because once a patient provides a specialist with an outside report, the specialist has the report forever. The patient does not have to worry about keeping up with the report for his or her next visit, and the facility where the procedure was performed does not have to worry about the patient calling for another copy of the report. Discrete data is the simplest for the EHR to use. The coded or field data can be instantly examined, recovered, shared, or conveyed in different ways. Field data places information in a particular section of the medical record while coded data contains field data with additional descriptive text. For example, a codified EHR medical record of an unchanged lower back problem may look like this: 9442, lower back injury, 31231441, improved, or

UNIT II STUDY GUIDE

Functional EHR Systems and Learning Medical Record Software

HTH 2305, Health Information Documentation Management 2

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31210539. A code set created to document medical interpretations is called a clinical nomenclature (Gartee, 2017). Utilizing EHR nomenclature offers uniformity in a patient’s medical records and enhances communication among diverse medical specialties. EHR nomenclatures and coding requirements are different. EHR nomenclatures link specific terms into clinical observations that are a medical necessity to the physician. EHR nomenclatures contain cross-references to additional code set guidelines. Coding formats not designed for EHR normally do not include a map to outside coding systems. Billing codes often only describe the service rendered during a single doctor’s visit. EHR nomenclatures explain in detail the patient’s chief complaint, medical history, clinical observations, and treatment plan. Each of these components is important because they reduce the timeframe needed to document the visit. In addition, if the patient returns for the same chief complaint, the physician can follow up with the patient to see if he or she is complying with the treatment plan. Have you ever known someone who is constantly at the doctor but will never take the medicine prescribed by the physician, exercise, follow the dietary requirements, or attend therapy sessions? EHR nomenclatures allow the physician to quickly identify non-compliant patients and help him or her design a new treatment plan for the patient to follow (Gartee, 2017). The primary coding standards in an EHR are Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT), Medcin, Logical Observation Identifiers Names and Codes (LOINC), and Clinical Care Classification System (CCC). The United Kingdom’s National Health Service and the College of American Pathologists established the medical nomenclature SNOMED-CT. SNOMED-CT contains more than 980,000 concept names, description, and synonyms that can be cross-referenced to ancillary code sets (Gartee, 2017). Medcin is a medical nomenclature created for physicians to use at the point of care. Medcin reduces the quantity of individual codes the physician has to enter into the patient’s progress note. LOINC is the clinical terminology for laboratory request and findings. CCC is a set of codes for nursing associated with different EHR nomenclatures. There are also billing codes that differ from EHR nomenclature. These will be discussed later in the course, but for now, it is important to be familiar with two of these systems. First is ICD-10. The ICD-10 is used to code and classify mortality data from death certificates; this coding manual replaced the ICD-9. ICD-10CM is the replacement for ICD-9CM, volumes 1 and 2; this was effective October 1, 2015 (Gartee, 2017). The World Health Organization (WHO) owns and publishes this coding manual. The ICD-10 is a great coding tool; this manual goes into more detail when it comes to coding a diagnosis. This manual had huge coding changes to make sure the coder can diagnose the codes and more easily locate the codes in the manual. The change of the ICD-10 was needed because ICD-9 was outdated and hard to use. One of the biggest reasons for the change was because electronic medical records (EMR) were put in place and needed updated diagnosis codes. This allows the system to easily locate the codes electronically. The current procedural terminology (CPT) is a coding manual used to code for procedures. It is a medical code set that is maintained through the American Medical Association (AMA). The CPT list codes for surgical, medical, and diagnostic services. The CPT is released every October. Patient-entered data may become a new component of EHR (Gartee, 2017). The program Instant Medical History permits patients to enter medical history and chief complaints prior to the doctor visit over the Internet or on a computer in the holding area. Is it a good idea to have patients documenting in their permanent medical records? Why or why not? Who knows your medical history and reason for visit better than you do? Physicians will continue to document in the EHR at the point of care. Here is how this can work. You sign into the facility electronically, then, you are called to take your weight and blood pressure. This information is entered electronically, also. Once your physician or medical staff member enters the room, he or she will most likely use a tablet to enter data on the visit. This allows the physician to take notes more easily and allows more time to be spent with the patient and the information to more quickly be sent to other facilities and physicians. There has been much written about who owns the medical information data that are entered into EHR. This is a debatable topic that depends on the healthcare organization. The patients will always be allowed to gain access to their medical records, so they own the files just as much as the healthcare facility that keeps the documentation. No healthcare facility will ever give up all information without having a copy of the originals on file. If a patient requests medical documents, he or she would be given a copy, and the facility would have a copy. Thinking about it like this, it may seem that the healthcare facility owns the documentation.

HTH 2305, Health Information Documentation Management 3

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Coded EHR information is utilized for trend analysis, alerts, health maintenance, and decision support. Trend analysis allows the physician to monitor a patient’s medical findings over a specific timeframe (Gartee, 2017). Alerts prevent interaction of multiple drugs and notify the physician when lab results are out of normal limits. Decision support locates educational material for physicians. It provides them with current standard care regulations, protocols, and recent medical research. Health maintenance reminds patients of preventive health examinations. Most individuals do not take time out for health maintenance, but just as a vehicle needs an oil change, maintenance of the body is also needed. There should be time taken every year to obtain the recommended physicals. With the busy lives that most live, do you appreciate getting the letter in the mail or phone call reminding you that it is time for the children’s immunizations or that it is time for your annual health screening? Educational tools are in place to make sure that individuals are eating right, exercising, and not smoking. Even with the educational tools, physicals are needed because of heredity illnesses that cannot be stopped. For instance, if someone has parents who both have cardiovascular issues, it is most likely that the child or children of those parents will have the same issues. With proper diet and exercise, it is possible that the end effect will not be as critical. The most important step in documenting the encounter is selecting the correct patient. How many times have you heard of the horrific stories of patients given the wrong medication and dying because of an adverse effect or surgeries performed on the wrong person or body part? When a patient goes in to have surgery, the patient is usually asked his or her name, birthdate, and the reason for the visit. The doctor typically will then mark the area where the surgery is taking place. This confirms that the patient and procedure is correct. Mistakes still take place in the hospital setting. If you have heard of one mistake, it is one too many. EHR was put into place to reduce errors like this, but because humans are entering the data, there is always a chance for a mistake to be made. That is why it is crucial that clinicians are not interrupted while taking a patient’s history or during the examination and that they identify the correct patient by name, date of birth, and wrist label identifier.

Reference

Gartee, R. (2017). Electronic health records: Understanding and using computerized medical records (3rd ed.). Boston, MA: Pearson.

Suggested Reading Chapter 3 is not part of the required reading in this unit, but you are strongly encouraged to view it and complete the exercises in it. Doing this will help you to learn the student edition software and be successful in the course. Chapter 3: Learning Medical Record Software

Learning Activities (Nongraded) Nongraded Learning Activities are provided to aid students in their course of study. You do not have to submit them. If you have questions, contact your instructor for further guidance and information. Student Edition Software As you are reading the required reading for this unit, it is important that you complete the following exercises in the MyHealthProfessionsLab. Doing these hands-on exercises will teach you the software and give you the foundation you need to complete this unit’s assignment. The exercises for this unit are as follows: Chapter 2 Guided Exercise 2A: Exploring a Document Imaging System, p. 44 Guided Exercise 2B: Importing and Cataloging Images, p. 51 Critical Thinking Exercise 2C: Retrieving a Scanned Lab Report, p. 61

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Chapter 3 Guided Exercise 3A: Understanding the Software, p. 74 Guided Exercise 3B: Adding Clinical Concepts to the Workspace, p. 83 Guided Exercise 3C: Patient with Caffeine Withdrawals Headache, p. 91 Guided Exercise 3D: Using the Details Pop-up Window, p. 97 Guided Exercise 3E: Recording Chief Complaint and Vital Signs, p. 102 Critical Thinking Exercise 3F: A Patient Suffering Withdrawal Headaches, p. 105