Clinical Documentation: Electronic Medical Record Systems

Course Overview

This MS in Health Care Informatics class introduces theory and applied practice of clinical documentation systems. Includes hands on experience with the use of Practice Fusion (an office-based EMR) and Cerner electronic medical record systems (EMR).

– 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.

– Emphasizes regulatory requirements for electronic medical records to include: HIPPA, Meaningful Use Requirements, security applications, and federal breach reporting.

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