HIM 1123 - Electronic Health Records

1. Define the medical record and electronic medical record.
2. Recognize, define, and use correct medical terminology for level of education.
3. Discuss legal and ethical issues in regards to medical information.
4. Apply HIPAA privacy policy in collection, recording, and release of protected healthcare information.
5. List items commonly found in the medical record.
6. Discuss role and responsibilities in data collection and recording.
7. Understand prominent EHR code sets and billing code sets.
8. Show how Evaluation and Management (E & M) codes are determined and why they are important in an EHR system.
9. Demonstrate starting the software, screen navigation, selecting the patient, and exiting the software. 
10. Create a patient encounter to include recording subjective findings, removing findings, adding detail (values, free text), and record the patient assessment, treatment plan, and physician’s orders.
11. Demonstrate how the EHR improves patient care.
12. Compare the use of workstations, laptop computers, Tablet PC’s and PDA devices.

• Students develop higher order thinking skills.
• Students can write clear, coherent, well-organized documents, substantially free of errors.
• Students can use computers proficiently.
• Students can employ a variety of sources to locate, evaluate, and use Information.