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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
Data Entry at the Point of Care

A healthcare professional spends a great deal of time during a patient encounter on documentation. The clinician must document the patient's symptoms, medical history, physician orders, observations, assessments, and all other aspects of the patient care. Documentation is extremely important for quality care and the health record must be accurate. Accuracy is improved when the clinician enters the data during the patient visit rather than later after the patient has left the facility. This is called point of care or real time data entry in the EHR.

The features of the electronic health record help to improve the efficiency of documentation. The EHR has numerous features that can tremendously save time for the clinicians in completing the required documentation.

After completing this resource, learners will be able to:

  • Use Forms
  • Use Review of Systems Load and use
  • Lists of Findings to speed up data entry
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
Data Entry Using Flow Sheets and Anatomical Drawings

When patients have an ongoing health problem or chronic disease, it is useful for the clinician to compare the health data in the record from past patient visits. This is quickly and easily done using Flow Sheets. This resource discusses how Flow Sheets are used and how clinicians can quickly enter data during a patient encounter by updating similar data from a previous encounter. Additionally, clinicians often find it useful to be able to annotate an anatomical drawing of a body region to be clearer in describing the location of findings, such as dermatological conditions.

This resource discusses how to invoke anatomical drawings and annotate them using a variety of drawing tools.

After completing this resource, learners will be able to:

  • Use an EHR drawing tool to annotate drawings in an encounter
  • Create a Problem-Based flow sheet
  • Create a Form-Based flow sheet
  • Work with flow sheets in the EHR system