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The Healthcare Record
Access to health information is changing the way doctors care for patients. Doctors now have access to a patient’s medical history, surgeries, allergies to medicines, and recent doctor’s visits all at the press of a button. This integration of technology and health information from a variety of sources is known as an electronic health record. Healthcare team members must understand how to use electronic record software in the ambulatory or inpatient setting. This includes inputting data into the electronic health record using the facility’s EHR software, updating the health record appropriately, and complying with all medical, legal, accreditation, and regulatory requirements associated with electronic health records. Some staff must also obtain information from the electronic health record to complete insurance claim information as well as billing, collections, and reimbursement tasks for the medical facility.
The Healthcare Industry
Credentials in Medical Administrative Assisting demonstrate competencies that include overall office operations, financial and practice management, basic billing and coding, privacy and handling of medical records, and overall professionalism in a medical setting. Specifically, this badge demonstrates the earner's ability to discuss the history and practice of medicine and the current healthcare environment.
Healthcare Facilities and Professionals

This resource provides an overview of the healthcare industry in terms of the numerous types of facilities available to serve patients and professionals who work within these facilities. Both facilities and professionals are guided by professional organizations designed to help set standards, provide information on best practices, monitor specialty areas, and provide many other services to healthcare workers and support the safety and quality of care for patients. Each patient generates a wealth of data that healthcare providers use in patient care, healthcare payers use in paying for services, and researchers use to study trends hopefully leading to improved care in the future. This data is gathered in the health record of the patient and then communicated to the various parties who use it.

The electronic health record facilitates this communication while at the same time has generated a new set of issues that must be considered and addressed. Let's begin the study of the electronic health record with a review of the healthcare industry in general.

After completing this resource, learners will be able to:

  • Identify the various organizations associated with the healthcare professions
  • Describe the roles of various healthcare professionals
  • Differentiate types of healthcare facilities
Basics of Medical Record Software

Although EHR systems serve basically the same purposes and have the same functions, each system is a bit different in its use, organization, and access to its various features. This resource introduces you to the basic functionality of the MEDCIN software. By learning how to use MEDCIN, you should be able to easily adapt to most other EHR systems.

This resource explains how to set up a patient account, document a patient encounter, and use basic navigation features of the software.

After completing this resource, learners will be able to:

  • Demonstrate navigation of the software
  • Document a patient encounter
  • Complete selected tasks to create a patient account
  • Use basic functions of medical record software using Medcin Student Edition Software
Problem Lists, Results Management, and Trending

The EHR provides many benefits. This resource discusses the use of Problem Lists, Results Management, and Trending features of the EHR and identifies how they are important tools for the physician in following patient problems, orders, medications, and disease progression or improvement.

After completing this resource, learners will be able to:

  • Create a graph of lab results and vital signs in the chart
  • View pending orders and lab test results
  • Use Problem Lists
  • Use Patient Management