HEALTH INFORMATION DOCUMENTATION

HTH 2305, Health Information Documentation Management 1

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

1. Utilize medical practice management software used in data entry. 1.1 Describe how electronic health records (EHR) preventative care systems work. 1.2 Explain the difference between a form-based flow sheet and a problem-oriented flow sheet. 1.3 Detail how annotated drawings are used in a medical environment.

8. Apply methods for assessing medical practice management principles and skills.

8.1 Discuss the purpose of flow sheets in a medical environment. 8.2 Outline the pros and cons of using electronic health records (EHR) as a preventative measure.

Course/Unit Learning Outcomes

Learning Activity

1.1 Unit lesson; Chapter 9; Essay

1.2 Unit lesson; Chapter 8; Essay

1.3 Unit lesson; Chapter 9; Essay

8.1 Unit lesson; Chapter 8; Essay

8.2 Chapter 9; Essay

Reading Assignment Chapter 8: Flow Sheets, Annotated Drawings, and Graphs Chapter 9: Using the EHR to Improve Patient Health, excluding Guided Exercise 9A and Guided Exercise 9C

Unit Lesson This unit illustrates how codified information in the electronic health record (EHR) could be presented in an arrangement termed a flow sheet. In addition, you will learn how to make a pediatric growth chart and transcribe a well-baby checkup utilizing a wellness form. Flow sheets submit information from several encounters in a vertical column arrangement (Gartee, 2017). The arrangement permits side-by-side assessment of results over a specific timeframe. The flow sheet display looks like a spreadsheet composed of cells. The initial column shows categories along with red and blue buttons for results on the existing encounter. The date of service of the existing encounter is located at the top of the column. The columns located to the right show encounter information from prior visits. Please make sure to take your time with the exercises in this unit to learn the software, and how to maneuver the software. The student edition software permits you to generate flow sheets using three methods based on list, problem, and form. When using a list, the initial column of the flow sheet is occupied by results in the list, results that are inside the tree display of the list, and results of comparable body systems. If the flow sheet were invoked as an alternate from the problem list on top of the Manage tab, the initial column was occupied by results associated to the particular problem in the problem list. When a flow sheet is invoked from a form, the EHR employs the information components on the form to occupy the initial column. When multiple forms are used throughout an individual examination to transcribe a patient with several chronic conditions, you can alter forms as frequently as you like throughout an exam without misplacing any of the information. Citing is the

UNIT V STUDY GUIDE

Data Entry Using Flow Sheets to Improve Patient Health

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process of transferring a result from a prior encounter progress note into the existing encounter. It is important to know how to move from the flow sheets to other parts of the system. The capacity to swiftly cite from a flow sheet speeds up the transcription process and guarantees that the physician remembers meaningful results from prior visits (Gartee, 2017). EHR systems have routing pages that permit the physician to quickly find results by aiming to specific parts of anatomy in a sketch, releasing a list of results pertinent to that body system. This function is defined as searching with images rather than terms. An alternative approach of adding information about the patient into EHR is the usage of anatomical drawings of the anatomic location. EHRs play a huge role in technology and only seem to grow with time. In the coming years, there will surely be more changes to the EHR system, which will only help the administration of healthcare. Ophthalmology and dermatology offices often use annotated drawings in the EHR. Annotated pictures generated in the EHR become a component of the electronic encounter and are valuable for patient education, in addition to transcription (Gartee, 2017). These images will display important information on the medical condition being treated. The patient will also be able to see an image that might give them a better view of what is being treated instead of the physician or nurse just speaking on the issue. With the advance of technology, the images will be more developed and easier to view. Anatomical drawings also play an important part during surgery. Prior to patients having surgery, X-rays are taken and reviewed by a radiologist. The radiologist and surgeon work as a team to locate and annotate the digital image with anatomical drawings and comments. The digital images are printed for the day of surgery and hung in the operating room for the surgeon to review prior to and during the procedure. The anatomical drawings ensure that the surgeon operates on the right part of the patient’s anatomy and removes the correct area of interest. Tools in the student edition software are invoked by selecting “Add Object” to the “Finding” from the pull-down list. A specific toolbar permits you to choose the shape, line, thickness, and color of the sketching apparatus. Furthermore, you can insert text box comments to the drawing and print the completed annotated drawing. In addition to annotated drawings, there are other ways that EHRs can be used to improve patient health. For example, an infant’s length, weight, and skull circumference are evaluated on every visit. Measurements charted on a graph termed a growth chart compares the patient’s growth to numerical data from the general population. This information can let the patients know where the child is at when it comes to growth and development. Lines on the graph termed percentiles signify the ratio of the population that was the equivalent size at the identical age (Gartee, 2017). A young child (5-11) who is in the 50th percentile weighs the equivalent or more than 50 percent of the general population at that age. For adolescents, the Centers for Disease Control and Prevention (CDC) currently suggest utilizing Body Mass Index (BMI). BMI is a calculation that quantifies body weight relative to height. BMI is calculated using the metric system. BMI for children is measured by gender and age; however, for adults, the same chart is used for both men and women. The CDC have substituted the original weight-for-stature graphs with the modern BMI charts (Gartee, 2017). As mentioned in the last unit, the BMI chart is often debated because of bone structure and different hereditary builds of the body. For instance, two women could weigh 150 pounds, but one woman could be taller and the other one short, or one woman could look very skinny but carry more muscle. Everybody is proportioned differently, and this can play a major role in the charting of the BMI. Immunizations should be provided over a specific timeframe. Immunizations reduce the risk of infection by decreasing the susceptibility of the host to infection. The Advisory Committee on Immunization Practices, the American Academy of Pediatrics, and the American Academy of Family Physicians cooperatively distribute immunization schedules for infants, children, and adolescents (Gartee, 2017). The CDC advises that immunizations be paired with the well-baby examination schedule. The National Coalition for Adult Immunization (NCAI) distributes comparable schedules for adults. Most individuals assume immunizations are solely for children; nevertheless, there are additional immunizations each adult should have. According to the NCAI, more than 50 percent of Americans over the age of 50 are not appropriately immunized against toxic diseases such as tetanus and diphtheria (Gartee, 2017). Vaccines are not allowed to be administered all at once. The National Childhood Vaccine Injury Act of 1988 requires physicians to record particular data about immunizations in the patient’s permanent EHR. Required data consists of:

 the type of vaccine, manufacturer, and medication lot number;

 the date of service;

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 the name, address, and professional title of the physician or healthcare professional that administered the vaccine;

 the site and route of vaccine administration; and

 the expiration date of vaccine (Gartee, 2017). The type of vaccine is important because it tells you why the vaccine is given. Knowing the manufacturer will let you see the advantages and disadvantages of the medications. The date of service will tell when the patient was given the medication. Another important note is who administered the vaccination, so if any issues arise, the patient can reach out to the person who administered the vaccine. The site and route will tell the location where the immunization was given, and the expiration date of the vaccine is very important because if it is out of date, it will not be effective and could cause issues for the patient. Parents must keep a precise, current immunization record for every child. This is essential information because a child’s medical record needs to be current at all times because of accidents that can take place. The immunization record serves as proof of immunization that is essential for day-care facilities, schools, and the military. Having immunizations recorded in EHRs is also important when parents change their children’s physician or relocate. Disease avoidance through routine screening and early detection helps save lives. Another way that EHRs can assist in a patient’s overall health is by helping with health maintenance. Health maintenance guidelines are created by the EHR system. Health maintenance guidelines suggest examinations and preventive measures based on an individual’s age and gender, but then alter the suggestions based on prior medical history exclusive to the individual. Utilizing the data, the physician can order examinations, explain pertinent treatment options, and suggest lifestyle modifications to the patient during consultation (Gartee, 2017). Electronic health records can offer just as many benefits for the patient as the health provider. Utilizing EHRs can assist patients by helping them keep track of their health and schedule yearly maintenance visits. This is just another great benefit provided by EHRs.

Reference

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

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 the assignments in this course. The exercises for this unit are as follows: Chapter 8 Guided Exercise 8A: Working with a Flow Sheet, p. 301 Guided Exercise 8B: Obstetric Patient’s Flow Sheet, p. 308 Critical Thinking Exercise 8C: Flow Sheet with Multiple Diagnoses, p. 316 Guided Exercise 8D: Annotated Dermatology Exam, p. 321 Critical Thinking Exercise 8E: Examination of a Patient with Pressure Sores, p. 330 Guided Exercise 8F: Trending with a Graph and Flow Sheet, p. 338 Critical Thinking Exercise 8G: Graphing Weight and BMI, p. 341 Testing Your Skill Exercise 8H: Diabetic with High Blood Pressure, p. 345

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Chapter 9 Guided Exercise 9A: Well-Baby Checkup, p. 348 Guided Exercise 9B: Pediatric Vitals and Growth Charts, p. 358 Guided Exercise 9C: Reviewing and Ordering Vaccines, p. 362 Critical Thinking Exercise 9D: Determine Your Adult Immunizations, p. 367 Guided Exercise 9E: Applying Quality Measures to Patient Care, p. 371 Critical Thinking Exercise 9F: Clinical Quality Measures for a Female Patient, p. 377 Testing Your Skill Exercise 9G: Baby’s First Checkup, p. 384