Electronic Health Records

EHR1

Electronic Health Records Course Overview:
This course will cover the usage and management of health information and the electronic health record (EHR). This course will introduce the students to the use of health information and the electronic health record for any setting within the health care industry from acute, ambulatory, long term, home health, specialty, population health, and personal health that encompass the continuum of care. This course will provide students with a practical understanding of what an electronic health record specialist is and how important they are in the job market today. This course will enable the students to assemble the patient’s health record and ensure all information is complete, properly identified and authenticated.

EHR Specialist’s duties will vary with size and specialty of the facility in which they may work. Many can specialize in varying areas or one aspect of the EHR such as entry-level coders, encoding within a hospital setting, abstractors and or coding specialist, HIPAA Compliance Officers or HIM (Health Information Managers) and be over entire departments within larger healthcare facilities.
The duties an electronic health records specialist may perform include but not necessarily be limited to:

  • Assemble patient’s health information to ensure information is complete and accurate
  • Enter data, such as demographic characteristics, history and extent of disease,
  • diagnostic procedures and treatment into computer
  • Statistical and Data Analysis for Quality Improvement Measures
  • Assist with special studies and research for public health agencies
  • Compile medical care and census data for statistical reports on diseases treated,
  • surgery performed, and use of hospital beds for clinical audits
  • Manage data backup, retention of records as well as maintain a variety of health
  • Record indexes, storage and retrieval systems
  • Work National Database Registries as a registrar, Contacts discharged patients, their
  • families, and physicians to maintain registry with follow-up information, such as
  • Quality of life and length of survival of cancer patients
  • Work with department managers to review policies and develops new workflows for
  • EHR, coordinate training resources and provides on-going end user training
  • Assist with the daily operations of the office. Duties may include answering the
  • Assist with the daily operations of the office. Duties may include answering the
  • reception area duties

Prerequisites:

1) Students should have completed training in or should have experience with:

  • Basic Medical Terminology
  • Basic Anatomy and Physiology
  • HIPAA and Medical Legal Aspects of Healthcare

2) Students should have an understanding of:

  • CPT-4 coding terminology
  • ICD-9CM coding terminology
  • HCPCS coding terminology

Coding is not necessary for electronic health record specialists, due to the fact that some offices use software that automates the coding process. Knowledge ofcoding terminology is strongly recommended. The coding terminology necessary is addressed throughout the recommended text.

3) Students should be proficient in operating a personal computer, including:

  • Demonstrated competency in: standard computer operating systems and electronic filing systems, basic keyboarding skills, organizing and sorting electronic documents;
  • Demonstrated knowledge of standard computer applications to include Microsoft Word and Excel;
  • Familiarity with using internet browsers and standard email systems such as MS Outlook

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