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Clinical Documentation: Electronic Medical Record Systems (HCIN 552)

Course Description

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.

Course Objectives:

  1. Analyze concepts and principles of information acquisition and management within an electronic clinical documentation system.
  2. Demonstrate basic skills in the use of electronic medical record systems.
  3. Describe types and applications of hospital data base systems that support electronic medical records including: ADT, PACS, DICOM, Pharmacy, billing and quality management systems.
  4. Analyze the use of BCMA systems and their ability to improve care delivery and reduce medical errors.
  5. Discuss principles of human factors in selection of hardware and software applications in clinical documentation systems.
  6. Demonstrate an understanding of EMR implementation strategies including workflow Create EMR screen builds that support work flow and clinical documentation.
  1. Demonstrate an understanding of the application of the electronic medical record to performance improvement metrics, required regulatory reporting, and securing health information.
  2. Critique strategies to secure health care information systems from internal and external risks and threats.

This is course is taken by Health Informatics Track & Health Care Analytics Track students who are in their final term. It is replaced by HCIN 625 – Digital Health Care Marketing for those in the Health Care Leadership Track.

Track Course

3 units