MDA 200 - Electronic Health Records

3 credit hours - three hours weekly; one term.
Formerly HIT 200

Learn the history and inception of the electronic health record and current health technology nomenclature and standards. Gain a broad perspective of current federal legislation and law governing the electronic health record. Learn to develop practical applications of the electronic health record, including types of medical software, administrative applications and functions for long-term planning, patient scheduling, tracking patient activity, e-communication within health systems, building the patient’s electronic face sheet and chart, electronic ordering and scheduling for testing and diagnostics, creating health forms, electronic health imaging, building health system and medical databases, electronic patient encounter forms and electronic billing systems in the health care setting. 

Prerequisite(s): Eligibility for ENG 101 /ENG 101A .

Note: Typically offered at MC and OL; fall and spring terms.

Course Outcomes:
 

1. Develop and maintain health data systems and structures
2. Integrate systems to maintain data integrity in compliance with national guidelines and laws
3. Develop and maintain clinical classifications systems
4. Develop non clinical support systems, such as financial and statistic programs that support overall operations
5. Integrate system technologies to support and maintain data integrity
6. Demonstrate effective and fluent e-communication technologies, including internal and external
7. Develop and maintain data storage and retrieval systems
8. Develop and maintain systems that support electronic health records, including imagery and other modalities that support patient diagnostics and treatment
9. Develop integrated systems that support real time communications of patient care and financial reimbursement

Accreditation outcomes

1. Identify common pathology related to each body system including:
   1. signs
   2. symptoms
   3. etiology
2. Analyze pathology for each body system including:
   1. diagnostic measures
3. Identify quality assurance practices in healthcare
4. Identify CLIA waived tests associated with common diseases
5. Define coaching a patient as it relates to:
   1. health maintenance
   2. disease prevention
6. Identify types of nonverbal communication
7. Define coaching a patient as it relates to compliance with treatment plan
8. Recognize elements of fundamental writing skill
9. Identify different types of appointment scheduling method
10. Identify the advantages and disadvantages of the following appointment systems:
    1. manual
    2. electronic
11. Identify critical information required for scheduling patient procedures
12. Define type of information contained in the patient’s medical record
13. Differentiate between electronic medical records (EMR) and a practice management system
14. Explain the importance of data back-up
15. Explain meaningful use as it applies to EMR applications of electronic technology in professional communication
16. Identify types of information contained in the patient’s billing record
17. Identify:
    1. information required to file a third party claim
    2. the steps for filing a third party claim
18. Outline managed care requirements for patient referral
19. Describe processes for precertification and preauthorization
20. Describe how to use the most current procedural coding system
21. Describe how to use the most current diagnostic coding classification system
22. Describe how to use the most current HCPCS level II coding system
23. Describe components of the Health Insurance Portability & Accountability Act (HIPAA)
24. Define living will/advanced directives
25. Verify the rules of medication administration:
    1. right patient
    2. right medication
    3. right dose
    4. right route
26. Differentiate between normal and abnormal test results
27. Use medical terminology correctly and pronounced accurately to communicate information to providers and patients
28. Coach patients regarding treatment plan
29. Compose professional correspondence utilizing electronic technology
30. Report relevant information concisely and accurately
31. Manage appointment schedule using established priorities
32. Schedule a patient procedure
33. Create a patient’s medical record’
34. Organize a patient’s medical record
35. File patient medical records
36. Utilize an EMR
37. Input patient data utilizing a practice management system
38. Perform accounts receivable procedures to patient accounts including posting:
    1. Charges
    2. Payment
    3. Adjustment
39. Obtain accurate patient billing information
40. Verify eligibility for services including documentation
41. Obtain precertification or preauthorization including documentation
42. Complete an insurance claim form
43. Perform procedural coding
44. Perform diagnostic coding
45. Protect the integrity of the medical record
46. Document patient care accurately in the medical record