HCIN-552: Clinical Documentation-Electronic Medical Record Systems

HCIN-552: Clinical Documentation—Electronic
Medical Record Systems

Table of Contents
Lead and Section Instructor Contact Information
Course Description & Learning Outcomes
Online Learning Requirements
Technological Requirements and Troubleshooting
Learner Responsibilities
Course Outline
Module 1: Introduction to CDS, HIPAA & Meaningful Use
Module 2: EHR Structure Part 1
Module 4: EHR Configuration
Module 5: Cyber Security & Cyber Hygiene
Module 6: EHR Certification Requirements
Module 7: Ontologies and Standards
Lead and Section Instructor Contact Information

Lead instructor and section instructor contact information is located in Blackboard.
Email
All email correspondence will occur within the Blackboard environment. All messages will be answered
within 24 hours, except on weekends when it will be 48 hours. It is imperative that you log in to
Blackboard regularly to check your correspondence.
Back to Top
Course Description & Learning Outcomes

Course Description
This course introduces theory and applied practice of clinical documentation systems. It includes hands-
on experience with the use of an academic electronic health record system via (EHR Go). This course
chronicles historical trends in the development and evolution of clinical documentation systems. Explores
hardware/software development requirements for EMRs and application of EMR data for: quality, risk
assessment, billing, and research applications. Includes overview of clinical devices that assist in
medication administration such as BCMA (Bar Code Medication Administration). Applies problem-based
learning to the development of clinical rules and alert systems for both Clinical Decision Support (CDS)
and CPOE (Computerized Physician Order Entry) systems. Course emphasizes regulatory requirements
for electronic medical records to include: HIPAA, Regulatory Requirements, security applications, and
federal breach reporting.
1 University of San Diego © 2020. All Rights Reserved.

Course Learning Outcomes
By the end of this course, you will be able to:
• Analyze concepts and principles of information acquisition and management within an electronic
clinical documentation system.
• Demonstrate basic skills in the use of electronic medical record systems.
• Describe types and applications of systems that support electronic medical records including:
ADT, PACS, DICOM, Pharmacy, billing, and quality management systems.
• Analyze the use of EHR systems and their ability to improve care delivery and reduce errors
including: CDS, CPOE, and BCMA.
• Discuss principles of human factors in selection of hardware and software applications in clinical
documentation systems.
• Demonstrate an understanding of EMR implementation strategies including workflow analysis
and use of EHR components to support workflow and clinical documentation.
• Demonstrate an understanding of the application of the electronic medical record to performance
improvement metrics, required regulatory reporting, and securing health information.
• Critique strategies to secure health information systems from internal and external risks and
threats.
Back to Top
Online Learning Requirements

To be successful academically, you must be able to navigate and search the web, use email, attach and
upload documents, download and save files, and have access to and use Microsoft Word, Excel and
PowerPoint. You are also expected to be familiar with web-based multimedia and related video-
production software, as well as free downloadable communication systems such a Skype. Please refer to
the new student orientation course if you have questions on any of these items.
Required Textbooks
Pepper, J. (2018) The Electronic Health Record for Physicians Office: For Simchart for the Medical Office.
(3rd Edition). St. Louis, MO: Elsevier.
Back to Top
Course Grading and Evaluation

Grading Criteria
The following are the assignments to be used in assessing your performance. All graded activities include
rubrics, which are located in the activity instructions. The related grading weight is based on a 1000 point
system:
Points Percentage Assignment
150 15% Module Discussions

Points Percentage Assignment
550 55% Module Assignments
300 30% Final Project
1,000 points 100% Total
Grading Breakdown
Letter Grade 1000 Point
A 940-1000
A- 900-939
B+ 870-899
B 830-869
B- 800-829
C+ 760-799
C 730-759
C- 690-729
D+ 660-689
D 630-659
D- 600-629
F 0-599
Discussion Board Criteria

Every module includes a forum with at least one discussion question. An initial response to each thread
prompt should be posted as early as possible, but no later than Day 4 of the module week. You are also
expected to actively engage with classmates in the discussion threads by posting at least two substantive
peer responses for each discussion thread prompt by the end of the module week.
Discussion Scoring Rubric
Criteria Achievement Level Achievement Level Achievement Level

Meets or Exceeds Approaching Below Expectations
Expectations Expectations
80 – 100% 70 – 79.9% 69.9% or Less
Initial Response Initial post fully addresses Initial post somewhat Initial response does not
the prompt and addresses the address the prompt or may
contributes in a prompt. Initial require significantly more
constructive way to the response may lack depth. Initial response may
50% discussion. Initial detail or explanation. be inappropriate for
response demonstrates Examples or professional context.
critical thinking skills and questions raised may
provides examples or require further Non-performance
details relevant exploration.
experience to
substantiate response.

Criteria Achievement Level Achievement Level Achievement Level
Meets or Exceeds Approaching Below Expectations
Expectations Expectations
80 – 100% 70 – 79.9% 69.9% or Less
Follow-up Responses to classmates Responses to Response posts are

Response clearly and constructively classmates add minimal or do not elicit a
build on the existing ideas, but may not robust response from
conversation. Responses connect to existing peers. Responses may be
elicit robust replies from conversation or may flat or rhetorical.
30% peers and are supported be inapplicable for
by examples, relevant professional context. No responses to peers.
experience, and further Examples or
questioning. arguments may
require further
exploration or detail
to appropriately
support dialogue.
Writing mechanics Student responses Student responses Student responses have

demonstrate quality have some spelling many spelling and
graduate level writing and grammar errors grammar errors and need
skills. Student posts are and need some major revision to meet
20% free of spelling and revision to meet expectations.
grammar errors. expectations.
Resources are not
Resources and Resources may not appropriately cited in APA
references are be appropriately cited format (where applicable).
appropriately cited in APA in APA format (where
format (where applicable).
applicable).
Make-Up & Late Work

Late assignments will NOT be accepted unless there are significant extenuating circumstances that have
been discussed with the instructor in advance of the assignment deadline.
Grade of Incomplete
The grade of Incomplete (“I”) may be recorded to indicate (1) that the requirements of a course have been
substantially completed but, for a legitimate reason, less than 25% of the work remains to be completed,
and, (2) that the record of the student in the course justifies the expectation that he or she will complete
the work and obtain the passing grade by the deadline. It is the student’s responsibility to explain to the
instructor the reasons for non-completion of work and to request an incomplete grade prior to the posting
of final grades. Students who receive a grade of incomplete must submit all missing work no later than
the end of the second week of the next semester, otherwise the “I” grade will become a permanent “F.”
Extra Credit
There are no opportunities for extra credit in this course.

Technological Requirements and Troubleshooting
Course Access and Navigation
Click here to see all course-related information posted on the Blackboard e-learning platform. You can
also access your course through the USD student portal. Click here to access the MySanDiego.edu.
System and Software Requirements

High-speed internet connection strongly encouraged (DSL or better)
A Windows environment is required. If you do not have a Windows-based laptop, it is recommended that
you purchase one for the program. If you are using an OS-based laptop, you must purchase software that
allows you to simulate the Windows environment, called VMware Fusion.
Computer: Windows Operating System: 32-bit and 64-bit Versions of Windows Vista, Windows 7, 8 or 10.
CPU Processor: 1.86 GHz Intel Core 2 Duo or greater. RAM: highest recommended for the operating
system or 2GB; Hard Drive: highest recommended for the operating system or 1GB of available space;
Screen Resolution must be 1024x768 or higher
OS Operating System: OS X 10.6 (Snow Leopard), OS X 10.7 (Lion), OS X 10.8 (Mountain Lion), 10.9
(Mavericks), and 10.10 (Yosemite). CPU: Intel processor, RAM: 4GB, Hard Drive: 1GB or higher available
space
Microsoft Office is required. If you are using Office 2010 or earlier, download and install the Microsoft
Office Compatibility pack.
Speakers or headset – to listen to multimedia
Webcam – for recording video
Email – To contact your faculty
Recommended Browser
Firefox is the recommended browser for use with Blackboard on both the Mac and PC. The Final
Release Channel version of Firefox is listed as certified or compatible with Blackboard. Chrome
(Mac/Windows) is also a supported browser.
Blackboard lists the most current browser compatibility information on its site (Click here for Blackboard’s
Help site.)
If you're having browser issues or your browser is locking up, try clearing your browser's cache.
Instructions for clearing your cache on the most common browsers are found here.
If components of your course are missing or broken, check to see whether your system is running the
most current version of Java. Click here to go to the Java website.
Windows Users: Test your version of Java here.

Mac Users: Click: Apple > Software Update

Browser Plugins
Windows Media Player (or Flip4Mac if you use a Mac), QuickTime, Flash, Shockwave, Adobe Reader,
and Java.
Technical Support
ITS Help Desk
(619) 260-7900
help@sandiego.edu
For basic questions, you can contact the Program Coordinator during regular business hours.
Back to Top
Accessibility and Usability

Technology Accessibility Statement Links
Blackboard Learning Management System Accessibility Statement
Microsoft Office Accessibility Statement
Adobe Acrobat Accessibility Statement
Google – YouTube Accessibility Statement
Requesting ADA Accommodations

The University of San Diego is committed to promoting knowledge and academic excellence for all
learners. The University of San Diego's Disability and Learning Difference Resource Center helps
students with verified disabilities obtain meaningful academic accommodations and support to help
improve access to Professional and Continuing Education programs and courses.
If you are a student who would like to be considered for academic accommodations, please visit the
Disability and Learning Difference Resource Center and follow the instructions under Requesting
Services.
Back to Top
Learner Responsibilities
Research has shown that online students are self-starters and highly motivated. The fact that you sought
out this learning experience and are enrolled in an online class affirms the research. You may have taken
an online class prior to this, or this may be your first experience with online education. Taking some time
to plan for your course of study can yield benefits and help ensure success.
Time Commitment
Any course of study requires a "time" for class. This online instructional environment requires you to
arrange your schedule to allow time for you to "attend" class on a regular basis each week. The time you
select is not important, but it is important that you log into your Blackboard course and complete the
activities and assignments on a regular basis. Each credit unit equals 12.5 core instruction hours;

therefore, in this 3-unit course you will have 37.5 instructional hours plus 75 hours of other course
activities. You can expect to spend about 15 – 18 hours per week in the class.
Online forum discussions are more valuable when all members of the group participate. Waiting until the
last minute of the final due date to post does not contribute to the dialogue. Planning a space and time for
studying and accessing the course frequently is paramount to your success.
Participation Requirements
Check your course every day and monitor/track deadlines accordingly. Participation and regular
attendance is an integral part of your overall success in the course.
Back to Top
Student Conduct/ Netiquette

Online learning brings together students from diverse locations and populations. This creates potential for
a rich learning community and also creates a need for thoughtful, courteous communications. Use a
professional and collegial tone in course dialogue. Refrain from using inappropriate or offensive
language. Humor can sometimes be a challenge because of the lack of cues in the online forum, such as
facial and body gestures and voice inflection. Be sensitive to these limitations and respectful to all
participants. It is the responsibility of all class members to foster a positive learning community.
Building Community
University of San Diego online courses are designed to be community-centered learning environments.
This means that the courses are designed to foster connections among the participants as you explore
common learning goals and interests. Each student brings unique characteristics and experiences to the
online classroom. Learn to use the course communication tools and begin creating connections right
away. It is the responsibility of all class members to foster social and academic interactions. Thoughtfully
share a bit about yourself, your ideas, experiences and new knowledge in the class forums to promote a
collaborative, rich learning environment.
Academic Integrity and Avoiding Plagiarism

Academic Integrity
You are expected to be knowledgeable about the principles of academic honesty and their application at
the University of San Diego. The Course Overview area of each course provides the Academic Integrity
Policy. You will be required to read the statement and pledge to adhere to the standards prior to
beginning the course. Academic dishonesty erodes the quality of scholarship and learning. As a student
at the University of San Diego, it is your responsibility to report incidents of academic dishonesty to the
proper authorities.
Avoiding Plagiarism
The nature of education and scholarship is the sharing of theories and ideas. Avoid plagiarizing by
providing a citation when using the words or ideas of others. It is your responsibility to give credit to the
sources of information you consult when developing written work. For this course, you are expected to
use APA style (sixth edition) for both formatting and citing references in your papers.

Withdrawal from Class
If you decide not to take a course that you registered for, you must contact the Program Coordinator on or
before the first day of class. If you fail to officially withdraw, you will be assigned a grade of “F” and
charged for the class. Please refer to the Drop and Withdrawal policies found in the Student Handbook.
Course Evaluations
End-of-course evaluations are collected via an online system that maintains student anonymity. The
information you provide in these evaluations is extremely important, as it is used to inform continuous
improvement of course content and instruction as well as faculty performance reviews. Course
evaluations are available in Module 6 of every course, and your participation is strongly encouraged.
Academic Grievance Procedures
Concerns about academic issues should be raised with your instructor first. If you are unable to resolve
the issue(s) with your instructor, contact the Academic Program Coordinator.
Back to Top
Course Outline
The following outline contains specific information on the learning modules, learning outcomes, and
assignments.
Module 1: Introduction to CDS, HIPAA & Meaningful Use

Module Introduction
In this module, you will learn about the history and content of electronic health records (EHRs). We will
identify who documents and owns the health record, EHR advantages and disadvantages, the role of
HIPAA in EHR implementation, and Meaningful Use guidelines. You will also be introduced to clinical
decision support systems for you culminating term paper in this course.
Learning Outcomes
• Recognize the content of a typical electronic health record (EHR).

• Distinguish the roles of the nurse informaticist and the clinical informaticist.
• Discuss the ANA Scope and Standards of Practice for Nursing Informatics.
• Describe the history and scope of HIPAA and patients’ rights as it relates to the EHR
Readings
• Ch. 1 from The Electronic Health Record for Physicians Office.

• Sections 1 and 2 of the Office of the National Coordinator for Health Information Technology’s
Health it Playbook
• Review the 2019 Program Requirements Medicare.
• Meaningful Use Overview
• Meaningful Use (CDC)
• HIPAA for Providers

• Understanding the Basics of Clinical Decision Support Systems
Presentation 1.1: Role of Informaticist in EHR Implementation
Presentations
• Watch Clinical Decision Support Systems. (04:27) Closed Captioning available on video
• Watch EHR Go Student Orientation Part 1 and Part 2. (04:23) Closed Captioning available on
video
• Watch The Role of a Clinical Informaticist Webinar. (28:23) Transcript
Discussion Questions
1.1 Introductions
Please take a few moments to introduce yourself to the class and share a bit about your
professional background, interest in this course, and any special concerns or interests. Indicate if
you have experience working in a health care organization (HCO).
What role do you envision taking in EHR implementation and its continued use?
For those with a clinical background, tie your roles to the American Nurses Association Nursing
Informatics: Scope and Standards of Practice. For those with a non-clinical background, refer to
the Health Information and Management Systems Society (HIMSS) “Role of a Clinical
Informaticist Webinar”. Post your introduction by Day 4 of this module.
After reviewing several of your classmates’ introductory posts, respond substantively to at least
two peers by Day 7.
Discussion 1.2 History
Review the module resources and by Day 4 of the module week, respond to the following prompt:
• One of the earliest recorded uses of a health record was in China in approximately 200 BCE by a
physician who kept records on the patients he treated. Since then, the way in which patient
information is documented has changed, but its core purpose of constructing a complete
collection of a patient’s health information remains the same.
o Discuss some of the positive and negative uses of the medical record in history.
o How does this history relate to patients' legal rights under HIPAA and the use of EHRs
today?
By Day 7, read your peers' responses and respond substantively to at least two of them.
Assignment 1.1: EHR Go

EHR Go is an education electronic health record (EHR) and learning platform. It is designed to help
students become proficient in EHR uses. As a health care informaticist, understanding how to navigate an
EHR is an essential part of the field.
For this module’s assignment, you will complete the following assignments in EHR Go:
• EHR Orientation

• Release of Information
The activity assignments can be found in Tab 1 “Overview & Resources” in the “Topic Resources”
section. Record your answers on the documents provided by EHR Go. Once complete, download the
documents from EHR Go and then upload them here in Blackboard.
Assignment 1.2: CDS Paper Introduction

Clinical decision support (CDS) systems are computer-based programs that analyze data within electronic
health records (EHRs) and provide prompts to healthcare providers to implement evidence-based clinical
guidelines at the point of care. As such, they are becoming essential tools for healthcare providers. For
example, implementing a smoking cessation CDS rule has been shown to decrease tobacco use. As the
volume of available patient data increases, the expectations for improved value-based care also
increases. As such, it is imperative as informaticists to understand what CDS systems are, their
capabilities, and how to best implement them into an electronic health record (EHR).
Overview of Final Project
Your final project for this course is to research a Clinical Decision Support (CDS) rule and its
application for an EHR. You will document your work in a term paper and short presentation. You will
complete a section of your project during each module over the course of seven weeks as outlined
below:
Module 1: Introduction
Module 2: Background Information
Module 3: Proposal: How to Utilize the CDS Rule
Module 4: Conclusion
Module 5: Abstract and Annotated References
Module 6: 5-Slide PowerPoint Presentation Highlighting Key Findings
Module 7: Final Draft of Paper
For this first assignment, you will write the introduction of your CDS term paper. Choose a CDS rule to
research and develop into a potential application for an EHR. Discuss the problem or issue the CDS Rule
will address. Possible sources of information include the Copley Library, CDC, and AHRQ websites.
Include in your introduction:
• Identification of CDS rule

• How it is applied
• The issues it addresses

Your introduction should be submitted as a Word document of 250-300 words. References should include
peer reviewed articles and all sources must have been published within the last five years. Use an APA
Style (7th Edition) to cite your references.
Conclusion
This module provided an introduction to EHRs - their usability in the healthcare setting, their advantages,
disadvantages, and the role EHRs play in HIPAA to maintain patient confidentiality. You reviewed
Meaningful Use guidelines and its role in EHR implementation. You also began formulating a CDS rule to
research and develop into a potential application for an EHR. In the next module, you will research
background information of your chosen CDS rule. We will also discuss the administrative sections of the
EHR and explore health-information exchanges.

Module Introduction
In this module, you will learn about the administrative sections of the EHR. These include patient
demographics and billing. You will also review health information exchanges and how this affects patient
engagement. You will also present the background information of your proposed CDS rule.
Learning Outcomes
• Discuss patient correspondence, including physician referrals, patient letters, secure email, and
faxing.
• Describe advantages and disadvantages of EHR systems.
• Identify the roles of various healthcare professionals in an EHR system.
Readings
• Ch. 4 from The Electronic Health Record for Physicians Office

• Health IT Playbook: Section 3 - Health Information Exchange
• Health IT Playbook: Section 5 - Patient Engagement
Discussion 2.1: Health Information Exchanges
• Health Information Exchanges (HIEs) can help organizations improve the delivery of quality care
and patient outcomes through improved health coordination.
o What are the advantages and disadvantages?
o Explain how healthcare organizations can work towards this goal and what obstacles
must be overcome to achieve it.
By Day 7, read your peers' responses and respond substantively to at least two of them. As you do,
consider disincentives to achieving the goal and draw from your professional experience if possible.


EHR Documentation Standards
Assignment 2.2: Background

In this section of your paper, discuss the background information of your chosen CDS rule. Possible
sources of information include the Copley Library, CDC, and AHRQ websites.
Include in this section:
• Background history of the issue CDS rule will address
The Background section of your paper should be submitted as a Word document of 350 - 500 words in
length. References should include peer reviewed articles and all sources must have been published
within the last five years. Use an APA Style (7th Edition) to cite your references.
Conclusion
In this module, you learned about the administrative sections of the EHR and reviewed health information
exchanges and how this affects patient engagement. In the next module, we will discuss the clinical and
ancillary sections of the EHR. You will also continue work on your CDS Rule paper by developing your
proposal.

Module Introduction
In this module, you will learn about the clinical and diagnostic sections of the EHR. These include clinical
documentation, medication reconciliation, prescribing, and ancillary sections. You will also present the
proposal for your CDS rule.
Learning Outcomes
• Describe the benefits of documentation in the electronic health record.
• Describe how to record vital signs and anthropometric measurements in the EHR.
• Discuss computerized provider order entry (CPOE) and the Problem List.
• Describe how to use the EHR for patient education.
Readings

• Health IT Playbook: Section 6 - Value-Based Care
• Computerized Provider Order Entry

• A Toolset for E-Prescribing Implementation in Physician Offices
Presentations
• Watch Bedside Medication Administration Workflow (02:48) Closed Captioning available on

video
• Watch Computerized Provider Order Entry, Part 1 (03:23) Closed Captioning available on video
• Watch Computerized Provider Order Entry, Part 2 (07:23) Closed Captioning available on video
• Watch Clinical Decision Support Systems (04:27) Closed Captioning available on video
Discussion 3.1: EHR Go
Electronic health records enable health care providers quick access to patient records for more
coordinated and efficient care in a secure environment. In this week’s discussion, examine why proper
documentation in the EHR is important and the unintended consequences of improper documentation.

• Introduction to Clinical Reminders
Assignment 3.2: Proposal
In this section of your paper, provide justification on how your chosen CDS rule will be utilized. Possible
sources of information include the Copley Library, CDC, and AHRQ websites.
In the Proposal section of your paper, include:
• Description of how the CDS rules will be utilized

• Justification for creation Actions to take to implement the CDS rule
• Identify necessary team members and their roles
• Steps needed to obtain stakeholder approval.
The Proposal section of your paper should be submitted as a Word Document of 750-1000 words in
length. References should include peer reviewed articles and all sources must have been published
within the last five years. Use an APA Style (7th Edition) to cite your references.

Conclusion
In this module, you learned about the clinical and diagnostic sections of the EHR. In the next module, we
will discuss EHR configuration and discuss the basic functions of barcode medication administration,
computerized provider order entry, and clinical decision support features. You will also continue work on
your CDS Rule paper by developing your conclusion.
Module 4: EHR Configuration

Module Introduction
In this module, you will learn about the basic functions of EHR software that include barcode medication
administration, clinical decision support, and computerized provider order entry systems. You will also
formulate the conclusion of your CDS rule.
Learning Outcomes
• Describe the basic functions of barcode medication administration (BCMA) features of EHR
software.
• Describe the basic functions and advanced clinical decision support (CDS) features of EHR
software.
• Describe the basic functions of computerized provider order entry (CPOE) systems for the EHR
Readings
• Implementing Clinical Decision Support Systems

• The Five Rights of Clinical Decision Support
• Clinical decision support systems for improving diagnostic accuracy and achieving precision
medicine
Presentations
• Watch Bedside Medication Administration Workflow. (02:48) Closed Captioning available on

video
• Watch Computerized Provider Order Entry, Part 1. (03:23) Closed Captioning available on video
• Watch Computerized Provider Order Entry, Part 2. (07:23) Closed Captioning available on video
• Watch Clinical Decision Support Systems. (04:27) Closed Captioning available on video
Discussion 4.1: Design Efficiencies
• Identify and discuss an aspect you consider important to EMR user interface design that supports
efficiency in EMR documentation.

Discussion 4.2: Barriers to Efficiency in EMR Documentation
• Identify and discuss an aspect of EMR user interface design that may be a barrier to efficiency in
EMR documentation.
• Implementing Clinical Decision Support

• Cause and Effect: CDS Evaluation
Assignment 4.2: Paper Conclusion

In this conclusion of your paper, summarize the key points of your CDS rule proposal. Possible sources of
information include the Copley Library, CDC, and AHRQ websites.
In the conclusion section of your paper, include:
• Summarize key points of the CDS rule proposal

• Overall recommendations for smooth implementation
• A timeline for implementation
This section of your paper should be submitted as a Word Document of 250-300 words in length.
References should include peer reviewed articles and all sources must have been published within the
last five years. Use an APA Style (7th Edition) to cite your references.
Conclusion
In this module, you learned about the basic functions of EHR software for BCMA, CDS, and CPOE
systems. In the next module, you will learn about cyber security and cyber hygiene and how to maintain
protected health information. You will also write the abstract and provide annotated references for your
CDS rule.

Module 5: Cyber Security & Cyber Hygiene
Module Introduction
In this module, you will learn about cyber security and cyber hygiene. These topics are vital to the
healthcare industry to prevent cyber attacks and protect patient information. You will also write the
abstract and provide annotated references for your CDS rule paper.
Learning Outcomes
• Identify the types of security safeguards in the medical practice.

• Discuss access to protected health information, including who has legal access to patients’
records and under what circumstances.
• Discuss methods that health care providers and patients can use to protect their health
information.
Readings

• Health IT Playbook: Section 7 - Privacy & Security
• Understanding Electronic Health Records, the HIPAA Security Rule, and Cybersecurity
• CDC: Public Health & Promoting Interoperability Programs (formerly known as EHR Meaningful
Use)
• HIPAA Basics for Providers: Privacy, Security, and Breach Notification Rules
• State Data Security Breach Notification Laws
Discussion 5.1: Cyber Security Breaches
• Provide real-life example of cyber security breach of a hospital and discuss the following:
o Did they follow breach protocol? (i.e., how long did it take them to notify affected
individuals?)
o What cyber hygiene techniques should have been utilized?
o What will they do to mitigate future threats?
• Introduction to Privacy and Security
Assignment 5.2: Abstract & Annotated References

Abstract

Now that you have completed the first draft of your final project and have incorporated feedback from
your instructor, it is time for you to write the abstract. For help with your abstract, access the online writing
lab (OWL) at Purdue University.
Your abstract must include a brief (120 or fewer words) statement that summarizes the main points of the
paper to follow.
Annotated References
Submit a list of resources you used throughout your final project. Along with the references (cited in
appropriate APA format), provide some annotation for the reader. Your annotations should include the
following:
• A brief description of what is contained in the article or text.

• How it relates to your chosen final project topic.
Submit your Abstract and Annotated References as two separate Word documents, free of spelling and
grammar errors.
Conclusion
In this module, you reviewed the importance and best practices for cyber security and cyber hygiene. You
also wrote the abstract and provide annotated references for your CDS rule paper. In the next module,
you will review EHR certification requirements. You will also submit a 5-slide powerpoint presentation for
your CDS rule.
Module 6: EHR Certification Requirements

Module Introduction
In this module, you will review EHR certification requirements and review the importance of operability
between related systems. You will also submit your final paper for your CDS rule and begin preparing
your final presentation.
Learning Outcomes
• Describe the need for interoperability between personal health records, EHRs, and related
systems.
• Describe Meaningful Use guidelines and the need for a certified EHR.
Readings

• Health IT Playbook, Section 8: Quality & Patient Safety
Discussion 6.1: Personal Health Records
• How can the interoperability of a patient's personal health record and the EHR improve an
individual's health behavior?

By Day 7, read your peers' posts and respond substantively to at least two of them. In your peer
response, describe how these improvements align with Meaningful Use guidelines.
Discussion 6.2: Peer Review of Draft Presentation

Review the instructions for the CDS Rule Project PowerPoint assignment located in this module (due Day
7 of Module 7). By Day 7 of this module, post a draft of your five CDS Rule Project PowerPoint slides to
this discussion thread. This is an opportunity to receive feedback from your peers that you may want to
include before your final submission of your presentation in Module 7. Your final presentation will require
audio, but you are not required to provide audio on this draft version.
In your peer responses, provide constructive feedback to two of your peers’ CDS Rules and
presentations.
During Module 7, return to this discussion thread to review your peer feedback so there is time to make
edits before your final presentation submission.
Assignment 6.1: CDS Rule Paper - Final Draft

In this module, you will turn in the final draft of your CDS Rule paper. The final draft should include all of
the elements you have created throughout the course including the abstract and annotated reference
pages. Your final paper should also incorporate all of the feedback you have received from your instructor
and should total 5-7 pages in length.
Your final draft must include:
• A title page
• Abstract
• Discussion of the program or issue the CDS rule will address
• Description of valid sources for background information on the CDS problem
• Description of how the CDS rule would be utilized to address the intended problem or issue
• Annotated reference page
Adhere to APA formatting and citation standards. For help with APA formatting and citation standards,
visit the online writing lab (OWL) from Purdue University.
Conclusion
In this module, you reviewed EHR certification requirements and the importance of interoperability
between related systems. You submitted a final draft of your CDS Rule Paper and also submitted a draft
of your PowerPoint presentation for your CDS rule in order to give and receive constructive peer
feedback about the presentations. In the next module, you will learn about EHR standards, review an
overview of ontologies, and billing and coding requirements. You will also submit the final draft of your
CDS Rule Presentation.

Module 7: Ontologies and Standards
Module Introduction
In this module, you will examine an overview of EHR standards and ontologies, billing and coding
standards, and Meaningful Use requirements. You will also submit your final 5-slide narrated presentation
of your CDS rule.
Learning Outcomes
• Discuss the roles of the patient, provider, and third-party payer in the healthcare reimbursement
process.
• Discuss medical coding, the role of the EHR in medical coding, and the Current Procedural
Terminology (CPT) system.
• Discuss the concept of medical necessity and indicate how it affects third-party reimbursement.
• Define fraud and abuse.
Readings
• Health Information Exchange (HIE)

• San Diego Health Connect
• DICOM (Digital Imaging and Communications in Medicine)
Discussion 7.1: Definitions

• For this discussion, define each item listed below and describe how they relate to interoperability.
o HL7
o ICD-10 / ICD-11
o CPT
o SNOMED CT
o DICOM
By Day 7, read your peers' posts and respond substantively to at least two of them. Select one of their
definitions and describe its vital role in the EMR.

• Health Information Terminology
Assignment 7.2: CDS Rule Project Presentation

The ability to disseminate information effectively to stakeholders is an important aspect of any project to
obtain support and receive approval. For this assignment, you will create a five-slide PowerPoint of your

proposed CDS Rule. You will “present” your PowerPoint using USD's Screencast-o-matic application,
linked below.
Your presentation must include the following content:
• Title Slide
• Introduction (Discussion of the problem or the issue the CDS rule will address)
• Background information
• Proposal
• Conclusion
The length of your presentation must not exceed 15 minutes.
Conclusion
Congratulations! You have completed this course! Through your discussions, assignments, and project,
you have:
• analyzed concepts and principles of information acquisition and management within an electronic
clinical documentation system,
• demonstrated basic skills in the use of EMRs,
• described the types and applications of systems that support EMRs,
• analyzed the use of EMR systems and their ability to improve care delivery and reduce errors,
• discussed principles of human factors in the selection of hardware and software applications,
• demonstrated an understanding of EMR implementation strategies to support documentation,
• demonstrated an understanding of the application of the EMR to performance improvement

metrics, required regulatory reporting, and securing health information, and critiqued strategies to
secure health information systems from internal and external risks and threats.
Back to Top

HCIN-552: Clinical Documentation-Electronic Medical Record Systems

Hochgeladen von

Dokumentinformationen

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

HCIN-552: Clinical Documentation-Electronic Medical Record Systems

Hochgeladen von

Copyright:

Verfügbare Formate

HCIN-552: Clinical Documentation—Electronic

Medical Record Systems

Lead and Section Instructor Contact Information

Course Description & Learning Outcomes

1 University of San Diego © 2020. All Rights Reserved.

Online Learning Requirements

Course Grading and Evaluation

Points Percentage Assignment

150 15% Module Discussions

2 University of San Diego © 2020. All Rights Reserved.

550 55% Module Assignments

300 30% Final Project

1,000 points 100% Total

Discussion Board Criteria

Discussion Scoring Rubric

Criteria Achievement Level Achievement Level Achievement Level

80 – 100% 70 – 79.9% 69.9% or Less

3 University of San Diego © 2020. All Rights Reserved.

80 – 100% 70 – 79.9% 69.9% or Less

Follow-up Responses to classmates Responses to Response posts are

Writing mechanics Student responses Student responses Student responses have

Make-Up & Late Work

4 University of San Diego © 2020. All Rights Reserved.

System and Software Requirements

Speakers or headset – to listen to multimedia

Webcam – for recording video

Email – To contact your faculty

Windows Users: Test your version of Java here.

5 University of San Diego © 2020. All Rights Reserved.

Accessibility and Usability

Microsoft Office Accessibility Statement

Adobe Acrobat Accessibility Statement

Google – YouTube Accessibility Statement

Requesting ADA Accommodations

6 University of San Diego © 2020. All Rights Reserved.

Student Conduct/ Netiquette

Academic Integrity and Avoiding Plagiarism

7 University of San Diego © 2020. All Rights Reserved.

Academic Grievance Procedures

Module 1: Introduction to CDS, HIPAA & Meaningful Use

• Recognize the content of a typical electronic health record (EHR).

• Ch. 1 from The Electronic Health Record for Physicians Office.

8 University of San Diego © 2020. All Rights Reserved.

Presentation 1.1: Role of Informaticist in EHR Implementation

Discussion 1.2 History

Assignment 1.1: EHR Go

9 University of San Diego © 2020. All Rights Reserved.

Assignment 1.2: CDS Paper Introduction

Overview of Final Project

Module 2: Background Information

Module 3: Proposal: How to Utilize the CDS Rule

Module 5: Abstract and Annotated References

Module 6: 5-Slide PowerPoint Presentation Highlighting Key Findings

Module 7: Final Draft of Paper

Include in your introduction:

• Identification of CDS rule

10 University of San Diego © 2020. All Rights Reserved.

Module 2: EHR Structure Part 1

• Ch. 4 from The Electronic Health Record for Physicians Office

Discussion 2.1: Health Information Exchanges

Assignment 2.1: EHR Go

11 University of San Diego © 2020. All Rights Reserved.

EHR Documentation Standards