Electronic Health Record (EHR)

EHR for HIM

Implementation of an electronic health record (EHR) at any health care organization is a complex and lengthy process, requiring preparation and changes in essentially all areas of a medical facility. Rolling out the EHR will require a considerable training effort at the time of implementation, as well as an ongoing program of training and support. Health Information Management (HIM) professionals provide ongoing operational support for certain RPMS packages that are part of or interface with the Electronic Health Record. The goal of this training is to (a) provide HIM professionals with basic skills for supporting the IHS EHR and (b) delineate recommendations for specific HIM issues. The target audience for this course is the health information management professionals and Clinical Application Coordinators (CAC).

The first part of this hands-on class will provide participants with the knowledge, skills, and abilities to fully utilize the EHR in the HIM setting. At the end of this session participants will be able to:

Navigate throughout EHR tabs
Set up personal preferences and views
Enter and amend progress notes
Document exams, patient education, immunizations and skin tests
Assign ICD-9 (including E-codes), CPT, and HCPCS codes
Perform late entry of notes
Complete a consult
Enter allergies and vital signs
Perform pharmacy, laboratory, and radiology order entry
Update the problem list

The second part of this class is the most intense and will review the tools necessary for setting up the EHR for optimal HIM utilization. At the end of this session participants should be able to:

Set up a user (Chief MIS, Medical Record Technician, Coder)
Review specific notifications that affect HIM
Set up basic document parameters that affect HIM
Import a Text Integration Utility (TIU) template
Set up a consult service
Set up keys and parameters needed to enter Patient Care Component (PCC) data to include (a) creating a superbill, (b) creating an ICD-9 pick-list, and (c) setting up a health summary.
Delete a Progress Note

The third part of this training will (a) identify specific HIM issues surrounding the use of EHR and (b) delineate recommendations concerning these issues. Issues identified by both EHR sites and Users to date include:

Documentation of Immunizations and Skin Tests
Documentation of Phone Calls, Chart Reviews and Coordination of Care
Review PCC Error Reports
Documentation of Paperless Refills
Documentation of Patients who leave without being seen
Review the "HIM Business Process Recommendations for EHR"
Recommend "Coding Tools"