it healthcare manual 020612 sample

7/30/2019 IT Healthcare Manual 020612 Sample

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No part of the student manual can be reproduced in any form without prior wrien permission from MedPro.

Stu

Course Developer MedPro

A Division of ECPI University

Development Team Marie Twigg, BS, A+, Network+, Security+,

Project+, Linux+, Server+, CTT+, HIT, i-Net,

CDIA+, MCT

Ryan Sco Williams, BS, MCSE, MCT, VCP,

EMCPP, HIT

Randal Beard, M.Ed, CPA, RMA

Eding Team Larry Hill, BS, RMA, AHI

Trudy Gaba, BA English

Joseph Price, A+, Network+, MOUS

Chrise Adams, MOUS

Layout and Graphics Soa Bergin, Master of Fine Arts,

Graphic Design and Communicaons

ALL RIGHTS RESERVEDNo part of this work may be reproduced, transcribed, or used in any form or by any

means; graphic, electronic, or mechanical, including photocopying, recording, taping,

web distribuon or informaon storage and retrieval systems without wrien permis-

sion from MedPro.

All MedPro manuals are supplied on the basis of a single copy of a course per student.

LIMITATION OF LIABILITYEvery eort has been made to ensure complete and accurate informaon. Neither

MedPro, the developers or publisher can be held legally responsible for any mistakes

in prinng or for faulty instrucons contained within this course. MedPro reserves the

right to revise this manual and make changes from me to me in its content without

noce.

The contents of this material were created for the CompTIA Healthcare IT Professional

Cercaon exam (HIT-001) covering the CompTIA cercate objecves that are current

as of 01/12.

For addional manuals, and/or volume purchase programs, contact:

[email protected] or call 757-419-3700.

Acknowledgement

Introducon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

T he Heal th ca re Ch al leng e for I T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

About this manual. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14ICON GUIDE: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Module 1HEALTHCARE FUNDAMENTALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Module 1 UNIT 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Organizaonal structures and dierent methods of operaon.. . . . . . . . . . . . . . . . . . . . 16

Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Private Pracce. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Nursing Homes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Assi sted Livi ng Faci lity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Home Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Hospice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Ambulator y Surgery C ente rs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Module 1 UNIT 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Medical Departments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Module 1 UNIT 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Code of Conduct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Adapng procedural behavior to dierent situaons and environments . . .29

Adapng social behavior based on sensivity of the environment. . . . . . . .30

The need to follow medical precauonary guidelines. . . . . . . . . . . . . . . . . . 31

Hand Cle ani ng Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Module 1 UNIT 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Basic Clinical Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Module 1 UNIT 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Medical Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Table of Contents

Table of Contents


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Student Manual Stu

Module 1 UNIT 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Medical Interfaces Fundamentals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Module 1 LABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Module 1 - Exam Objecves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Module 2COMPUTERS AND PERIPHERALS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Module 2 - UNIT 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Types of Computers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Module 2 - UNIT 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Peripheral Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

Module 2 - UNIT 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Medical Applicaons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Module 2 UNIT 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Peripheral Maintenance and Troubleshoong . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Keyboard Maintenance and Troubleshoong . . . . . . . . . . . . . . . . . . . . . . . . . 62

Mouse Maintenance and Troubleshoong . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Monitor and Display Device Maintenance and Troubleshoong . . . . . . . . . . 63

3D video . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

Troubleshoong and Maintaining Printers . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Ports and Connecvity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Module 2 - UNIT 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70Computer Troubleshoong and Maintenance Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Maintaining and Troubleshoong the Computer Operang System . . . . . . .71

Prevenve Maintenance and Troubleshoong . . . . . . . . . . . . . . . . . . . . . . . . 73

Motherboard Maintenance and Troubleshoong . . . . . . . . . . . . . . . . . . . . . . 74

Power On Self Test (POST) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Power Supply Unit (PSU) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

Basic Input/ Output System (BIOS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77

Complimentary Metal Oxide Semiconductor (CMOS). . . . . . . . . . . . . . . . . . . 78

Unied Extensible Firmware Interface (UEFI) . . . . . . . . . . . . . . . . . . . . . . . . . 78

CPU Maintenance and Troubleshoong. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

RAM (Random Access Memory) Maintenance and Troubleshoong . . . . . .80

Expansion Card Maintenance and Troubleshoong . . . . . . . . . . . . . . . . . . . . 80

Table of Contents

I mp or ta nt Thing s to Keep in Mind . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Module 2 - UNIT 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82Technical Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Module 2 - LABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Module 2 - Exam Objecves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Module 3NETWORK FOUNDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

Module 3 UNIT 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93OSI Module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

OSI Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

Router Setup and Conguraon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

Setup and Conguring Port Forwarding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

The Physical Network. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103

Network Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104

Internet Modem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104

Mobile Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

Tablets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

Portable Media Players . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Clinical Vendor Applicaons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

Module 3 - UNIT 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111Network Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

The TCP/IP Suite. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

Installing and Conguring DHCP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

Module 3 - UNIT 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119Foundaons of the Intranet and the Internet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Intranet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Internet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120

Extranet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

Peer-to-Peer Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120

Client-Server Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

Mainframe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

Terminal Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121

Virtualizaon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

API (Applicaon Program Interface). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122

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Ethernet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .122

Computer Applicaons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

Applicaon Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

Applicaon Languages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126

Module 3 - UNIT 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131Wireless Connecvity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

Methods of Wireless Connecvity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132

Wire less Ac cess Point S ec ur ity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133Bluetooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134

Wireless Access Point Conguraons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134

Guest Networks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136

Module 3 - UNIT 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137Network and Business Communicaons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

Email . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

Instant Messaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138

Short Message Service (SMS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

Telecom / Voice Over IP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140

Electronic Medical Records (EMR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

Facsimile (Fax) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142

Secure FTP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .143

Database Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

Data Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

Types of Databases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145

Database Languages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146

Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146

Applicaon Servers and Interfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

Network Troubleshoong . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

Layered Network Troubleshoong Essenals . . . . . . . . . . . . . . . . . . . . . . . . 147

The L ogical N etwork. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

Troubleshoong Common Network Issues . . . . . . . . . . . . . . . . . . . . . . . . . . 149

Module 3 - LABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152

Module 3 - Exam Objecves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158

Module 4HEALTHCARE ENVIRONMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

Module 4 - UNIT 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

Table of Contents Table of Contents

Medical Devices in the Medical Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

Interface Problems with Hea lthcare Devices. . . . . . . . . . . . . . . . . . . . . . . . . 164

Module 4 - UNIT 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167Clinical Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167

Clinical Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168

Module 4 - UNIT 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

Healthcare Soware Modules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

Module 4 - LABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172


Module 5MEDICAL INTERFACES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177

Module 5 - UNIT 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177Medical Interfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177

Provider Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .179

Module 5 - UNIT 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182

ePrescribing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182

Control led Substances and ePrescribing . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183

Module 5 - UNIT 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185Billing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185

EMR/EHR Outbound Communicaon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185

Types of Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .186

B il ling C lear ing hous e I nterfac e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187

Module 5 - LABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189


Module 6CLINICAL SOFTWARE AND CHANGE CONTROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194

Module 6 - UNIT 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195Clinical Soware and Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195


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Compability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196

Daily Business Expectaons and Upgrades . . . . . . . . . . . . . . . . . . . . . . . . . . 196

Soware Modules and Troubleshoong . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197

Support and Troubleshoong . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199

Module 6 - UNIT 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200Change Control Best Pracces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200

Module 6 - LABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203


Module 7DOCUMENT STORAGE AND MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206

Module 7 - UNIT 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207Storage Opons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207

Storage Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .207

Files . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207

File Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210

Storage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .213

Module 7 UNIT 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222Document Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222

Step 1: Document Preparaon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223

Installing and Conguring Imaging Devices . . . . . . . . . . . . . . . . . . . . . . . . . . 228

Module Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .234

Module 7 - LABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235


Module 8SECURITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240

Module 8 - UNIT 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240Authencaon Types. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240

Module 8 - UNIT 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245Physical Security. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245

Locaon for Hardware . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245

Environmental Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .248

Module 8 - UNIT 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253Access Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253

Roles and Responsibilies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253

Passwords . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .254

Directory Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255

Module 8 - UNIT 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258Cryptography and PKI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258

Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258

Hash Funcons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259

Symmetric Encrypon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259

Asymmetric Cryptography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .260

Other Uses of Asymmetric Cryptography.. . . . . . . . . . . . . . . . . . . . . . . . . . . 261

PKI (Public Key Infrastructure) and SSL (Secure Socket Layer) . . . . . . . . . . . 261

PGP (Prey Good Privacy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263

Module 8 - UNIT 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264Securing Communicaon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264

Module 8 - UNIT 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267Securing Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267

Module 8 - UNIT 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269Remote Access and Firewalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269

Te chnologi es and Hardware . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269

Types of F irewalls and Apply ing Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270

Remote Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271

HTTPS and FTPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271

Terminal Emulaon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272

SSH (Secured Shell) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272

RDC (Remote Desktop Connecon)/Remote Control Applicaons . . . . . . .272

Tunneling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .273

Module 8 - UNIT 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275Wireless Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275

Physical Implementaons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275

Secure Conguraon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276

Other Security Consideraons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277

Security Protocols. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .277


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Module 8 - UNIT 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278Business Connuity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278

Business Connuance (BC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278

Disaster Recovery (DR). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279

Disaster Recovery Pracces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280

Backup Conguraons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281

Backup Storage | Courier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .283

BRITTANIA HEALTH SYSTEMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285Informaon Technology Business Connuance and Disaster Recovery Plan . . . . . . . .285

Execuve Summary:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285

Disaster Recovery Summary:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285

Soluon Design: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287

RTO LEVEL I Funconal Priority: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289

RTO LEVEL II Funconal Priority: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289

Module 8 - UNIT 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291Healthcare IT Aack Venues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291

Security Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291

Module 8 - LABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293


Module 9REGULATORY REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305

Module 9 - UNIT 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305

Module 9 - UNIT 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308HIPAA Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308

Data Compliance / HIPAA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308

HIPAA Violaons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309

Module 9 - UNIT 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312Best Pracces and Documentaon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312

Legal Best Pracces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312

Business Associate Agreements (BAA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312

Module 9 - LABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314


ANSWERS TO LABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320Module 1 - LAB Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320

Module 2 - LAB Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324

Module 3 - LAB Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .329


Module 5 - LAB Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .338

Module 6 - LAB Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340Module 7 - LAB Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .342



Briania Health Systems Hands-on Virtual Labs . . . . . . . . . . . . . . . . . . . . 356

GLOSSARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383

INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408


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Student Manual StuIntroducon Introducon

IntroduconThe Healthcare Challenge for IT

Health informaon technology (HIT) provides the framework to demonstrate the com-

prehensive management of health informaon across automated systems and its secure

exchange between consumers, providers, government enes, and insurers. HIT is

viewed as the most promising tool for improving the overall quality, safety and eciency

of the health delivery system.

Expansive and consistent ulizaon of HIT will:

Reduce health care costs

Prevent medical errors

Improve health care quality

Increase eciencies

Reduce paperwork

Increase access to aordable care

The Informaon Technology profession is generally in the pracce of meeng the needs

of common professional business and enterprise vercals that may relate to Defense,

Legal, and Financial Instuons. The Healthcare industry is one of the most challenging

vercal markets for Informaon Technology today with regulatory requirements and dy-

namic laws that must be met. Healthcare IT connues to grow, as demand has increased

due to Government regulaons, Healthcare Reform, the American Recovery and theReinvestment Act. More than 88.5 billion was spent by providers in 2010 on developing

and implemenng Electronic Health Records (EHRs), health informaon exchanges, and

other Health Informaon Technology (HIT) iniaves. According to the study conducted

by the University of San Diego, HealthCare IT tops the list of hot careers and is ex-

pected to grow by 20% thru 2018. Healthcare connues to be a highly challenging and

rewarding career choice in the eld of IT.

The processes that are governed within a given healthcare organizaon rely heavily

upon the applicaons, systems, and networks that support the processes and which

processes are directly related to paent care and accessing life-saving data. Comput -

ers have become the crical tool of choice for paent care. Condenal and crical

informaon must be eciently stored, gathered, reported, and diagnosed by healthcare

professionals and specialists.

An IT professional in Healthcare needs to understand how essenal their role is within

an organizaon, being cognizant to perform with high security, opmal eciency and

under the most stressful circumstances. Medical professionals need to understand how

to use and opmize the automated tools available to provide comprehensive paent

care. Creang a centralized understanding between the IT professional and Healthcare

professional creates a powerful infrastructure to support the evolving medical industry.

CompTIAs Healthcare IT Technician is a vendor neutral Professional Cercaon. The

CompTIA Healthcare IT TechnicianProfessional Cercaon is designed to validate IT

professionals have the operaonal, regulatory, and security knowledge necessary to

provide hardware and soware support in medical environments where electronic

health record systems are being deployed and/or maintained. Addionally, the Profes-

sional Cercaon illuminates a commitment to work with, as well as, empathize with

the needs of Healthcare professionals by understanding the organizaonal behaviors

and pracces of a licensed Healthcare Organizaon.

This course provides an individual with the knowledge and skills required to implement,

deploy and support Health IT systems in various clinical sengs. Upon compleon of

the course, candidates will understand regulatory requirements, healthcare terminol-

ogy and hold an understanding of praccal workow while adhering to code of conduct

policies and securit y best pracces. The course prepares students for CompTIAs HIT-

001 Professional Cercaon exam.

About the HIT-001 Exam:

Exam Duraon: 60 minutes

Number of Quesons: 60

Passing Score: 650 on a scale of 100-900

The below table displays the domain areas measured during the examinaon, along

with the approximate degree to which they are represented in the examinaon as per

CompTIAs objecve guidelines.

Domain % of Examinaon

1.0 Regulatory Requirements 13%

2.0 Organizaonal Behavior 15%

3.0 IT Operaons 26%

4.0 Medical Business Operaons 25%

5.0 Security 21%

TOTAL 100%


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Student Manual StuAbout this manual About this manual

About this manual

This manual was designed to provide parcipants with an eecve roadmap to suc-

cessfully understand the Healthcare IT industry and to adequately prepare individu-

als for the Healthcare IT Cercate Exam (HIT-001). The course has been wrien by

a team of professionals with concentraons ranging from HealthCare Management,

Healthcare IT to IT Support Technicians. All individuals parcipang in the develop-

ment of the training materials hold both praccal experience in the industry, in addi-

on to a combined 45 years of instruconal experience. The course has been devisedto support the most eecve learning methods and it is our hope that you nd the

course a valuable learning tool. Your feedback is extremely important to us. All com-

ments and recommendaons will be taken into consideraon as future updates are

released. Feedback can be sent to: [email protected]

The manual consists of 9 modules to enable easy break points and support reten -

on. It begins by providing parcipants knowledge of the medical infrastructure,

then follows presenng parcipants an understanding of IT terms and tools. Holding a

foundaon in both the medical and the IT infrastructure allows for a natural bridge

between the two industry pracces, ulmately providing a centralized understanding

for the nal modules. In the nal modules, the best pracces to support regulatory

requirements, security requirements, and means to opmize resources for the health -

care organizaon are clearly outlined.

Aer each module, parcipants will have acvity labs to validate material retenon

and prepare for the HIT-001 cercate exam. At the end of the manual, parcipants

will nd virtual labs. The virtual l abs provide the opportunity for parcipants to experi-

ence hands-on understanding. As parcipants go through the labs, they will encounter

realisc situaons within a model health care organizaon, Britannia Hospital, where

they can take appropriate acons that parallel the content of each module.

Lastly, the manual is laid out with ICONS to help the parcipant easily transion be-

tween modules and to later use the manual as a reference guide.

ICON GUIDE:

MODULE INTRO

Introducon to the Module.

NOTE-TAKING

Throughout the module, parcipants

will noce ample area on each pagefor note taking.

WARNING

A note of warning!

MORE INFO

More Informaon on this topic can be

found in the Module/Unit referenced.

REVIEW Q

Review quesons to help test what the

parcipant has learned.

HANDS-ON LAB

A hands-on lab for parcipants to

pracce skills learned during this

module.

SLIDE

A slide accompanies the material.

OBJECTIVES

A lisng of objecves that support the

Cercate Exam.


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Student Manual StuModule 1 UNIT 1 Module 1 UNIT 1

Module 1HEALTHCARE FUNDAMENTALS

Working in a healthcare seng can be dierent from other industries. Its impor-

tant that a clear understanding of the industry, challenges and requirements of this

market be understood to properly support the unique necessies of the healthcare

eld. This module will provide you an overview of a healthcare organizaon as

concepts of the dierent types of healthcare structures, dierent departments,

dierent roles and responsibilies, dierent communicaon behavior require-

ments, clinical terms and medical interfaces are presented. Upon conclusion of this

module, you will have an overview of the healthcare terminology and environment

that is needed for an IT Healthcare Technician.

Module 1 UNIT 1Organizaonal structures and dierent methods of

operaon.

There are many types of medical facilies which exist to ll parcular needs of

paents. Whether the facility lls a specialized paent need or a general need,

paents need to be seen promptly and conveniently.

Hospitals

Most people think of a general hospital when they hear the word hospital. A

general hospital is set up to deal with many kinds of diseases and injuries, and

may have an emergency department to deal with immediate and urgent threats to

health. They oen have acute services such as an emergency department, burn

unit, surgery, or urgent care. The acute services may include more specialized units

such as cardiology or coronary care units, intensive care units, neurology, cancer

center, and obstetrics and gynecology departments. Support units in a hospital

usually include a pharmacy department, pathology department, and radiology

department. On the non-medical side, there oen are Medical Records Depart-ments, Informaon Management Departments, Maintenance Departments, Dining

Services, and Security Departments.

There are other types of hospitals that include:

Trauma centers

Rehabilitaon hospitals

Childrens hospitals

Geriatric hospitals

Psychiatric hospitals

Hospice centers

Private Pracce

Private pracce or clinics may include a single physician, mulple physicians, or a

physician pracce with a Physician Assistant (PA) or Nurse Praconer (NP). This

type of pracce may be general or specialized. A general or family pracce will

see most ages of paents and refer paents to a specialist if needed. With most

health maintenance organizaons (HMOs) insurances, these providers are the pri -

mary care physician (PCP). The PCP is the gatekeeper the paent must see before

going to a specialist.

Examples of specialty clinics would include:

Dermatology

Ear, Nose and Throat

Neurology Psychiatry

Pediatric

Womens clinic (OB\GYN)

Ambulatory (same day) Surgery

Ophthalmology

Gastroenterology

Nursing Homes

A nursing home or skilled nursing facility is a place for people who dont need to

be in a hospital but can not be cared for at home. Most of these facilies have

nursing aides and skilled nurses on hand 24 hours a day. The physician is not

always at the facility but the paents personal doctor or a sta doctor is available

by phone. The doctors examine paents and review the nursing notes periodi -

cally. The sta provides medical care, as well as physical, speech and occupaonal

therapy. Some nursing homes have special care units for people with serious neu-

rological problems such as Alzheimers disease and other forms of demena.


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Assisted Living Facility

Assisted living facilies (ALFs) provide supervision or assistance with acvies of

daily living (ADLs); coordinaon of services by outside health care providers; and

monitoring of resident acvies to help to ensure their health, safety, and well-

being. Assistance may include the administraon or supervision of medicaon,

or personal care services provided by trained sta personnel. ALFs are normally

populated by seniors, for whom independent living is no longer appropriate, but

who do not need the 24-hour medical care provided by a nursing home. Assisted

living is a philosophy of care and services promong independence and dignity. As-

sisted living facilies can range in size from a small residenal house for one resi-

dent up to very large facilies providing services to hundreds of residents. There is

no special medical monitoring equipment that you would nd i n a nursing home,

and nursing sta may not be available 24 hours. However, trained sta is usually

on-site around the clock to provide other needed services. Registered Nurses and

License Praccal Nurses are available by phone or on-call during o-hours to en-

sure proper aenon is provided to all residents.

Home Healthcare

Home health care is a wide range of health care services that can be given at

home. The goal of home health care is to treat an ill ness or injury without the pa-

ent traveling to a medical treatment facility. Home health care allows the paentto maintain their independence, and become self-sucient as soon as possible.

Home health care includes part-me or intermient skilled nursing care, and

other skilled care services like physical therapy, occupaonal therapy, and speech-

language pathology (therapy) services. Services may also include medical social

services or assistance from a home health aide.

Examples of skilled home health services include:

Wound care for pressure sores or a surgical wound

Physical and occupaonal therapy

Speech-language therapy

Paent and caregiver educaon

Intravenous or nutrion therapy

Injecons

Monitoring serious illness and unstable health status

Examples of other home health aide services that may be available include:

Help with basic daily acvies like geng in and out of bed, dressing,

bathing, eang, and other maers of personal hygiene

Help with light housekeeping, laundry, shopping, and cooking for

the paent

Hospice

The goal of hospice care is providing comforng care by relieving symptoms and

supporng paents with a life expectancy of up to six months or less. Hospice in-

volves a team approach with the medical personnel and family to provide medical

care, pain management and emoonal, as well as spiritual support. The emphasisis on comfort, not curing. Hospice may be provided in the paents home or in a

free standing hospice facility.

Ambulatory Surgery Centers

Ambulatory Surgery Centers (ASCs) are medical facilies that specialize in elecve

same-day or outpaent surgical procedures. Paents treated in these surgical cen-

ters do not require admission to a hospital and are well enough to go home aer

the procedure. Ambulatory surgery centers are stand alone facilies. Paents seen

at an ASC have to be referred by their PCP. These facilies also must also have at

least one room that is used only for operaons.

Examples of ASCs are:

cosmec and facial surgery centers

endoscopy centers

ophthalmology pracces

laser eye surgery centers

centers for oral and maxillofacial surgery


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orthopedic surgery centers

plasc surgery centers

mul-specialty surgery centers

Module 1 UNIT 2Medical Departments

Healthcare organizaons are large and can be made up of many medical depart -

ments. Departments are typically recognized by an area of specializaon. In

many cases, the departments can be represented with both inpaent and out -

paent available care. Oen, one may hear the terms outpaent or inpaent

used when referring to a type of diagnosc or therapeuc procedure. Inpaent

means that the procedure requires the paent to be admied to the hospital, pri -

marily so that he or she can be closely monitored during the procedure and aer-wards, during recovery. Outpaent means that the procedure does not require

hospital admission and may also be performed outside the premises of a hospital.

Here you will nd a list of the medical departments and notaons of whether the

department is typically seen as inpaent, outpaent or both.

DEPARTMENT DEFINITION INPATIENT/OUTPATIENT

Obstetrician/Gynecology

(OB/GYN)

This branch of medicine

includes providing care forall phases of pregnancies,

as well as, a wide variety

of genital tract diseases in

women.

INPATIENT

OUTPATIENT


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ONCOLOGY This eld covers the study

of tumors, both benign, or

noncancerous, and malig-

nant, or cancerous. Oncolo-

gists are specialized physi-

cians who diagnose, treat,

and provide informaon

on prevenve measures

against tumors. Cancer

registrars, who also work

in the Oncology eld, are

specialists in cancer data

management.

INPATIENT

OUTPATIENT

PEDIATRICS This is the medical specialty

that deals with the care and

development of children

from birth to usually age

18, as well as, the diagnosis

and treatment of all child-

hood diseases.

OUTPATIENT

INPATIENT

Family Birthing Center

(FBC)

Labor and Delivery (L&D)

Stork

Neonatal Intensive Care

Unit (NICU)

FBC, or Family Birthing Cen-

ter, as well as L & D (Labor

and Delivery), are special-

ized units in an inpaent

hospital seng that deals

with the care of newborns.

In Family Birthing Centers,

every aempt is made toaccommodate the expect-

ant mother and a select

number of family members,

to experience and share in

the birthing process. These

centers aempt to simulate

a more domesc, home-like

seng, while sll providing

quality care for the mother

and newborn. The NICU is

the Neonatal (newborn)

Intensive Care Unit, which

provides life-sustaining care

for newborns who face seri-

ous medical condions aer

delivery.

INPATIENT

Intensive Care Unit (ICU)

Cardiac Care Unit (CCU)

These specialized units in

an inpaent seng provide

highly specialized care for

crical paents. The ICU

is the Intensive Care Unit

whose paents are closely

monitored aer they have

been stabilized either

from a traumac accident,

chronic medical condion,

or aer major surgery. The

CCU, or Cardiac Care Unit,

specializes in the care of

cardiac paents.

INPATIENT

Primary Care Unit (PCU)

Transional Care Unit (TCU)

The PCU, or Primary Care

Unit, provides compre-

hensive acute and chronic

medical care in the same

environment, with main-

tenance in connuity of

care and physician-paent

relaonships.

A TCU, or Transional Care

Unit, is an environment

that bridges the gap be-

tween acute care (imme-

diately aer surgery) andpaent self-reliance such as

going home.

INPATIENT

MED/SURG This unit, in an inpaent

hospital seng, provides

care for post-surgical

paents without serious

complicaons, and for those

paents who have been

diagnosed with an acute or

chronic medical condion

that requires hospitaliza-

on.

INPATIENT


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PSYCHIATRY/BEHAVIORAL

HEALTH

This specialty can be either

in a hospital seng, or in

an out-paent clinic. This

branch of medicine deals

with paents that are suf-

fering from mental and

emoonal issues that could

stem from a wide variety

of reasons and causes. The

treatment of these paents

may result in long-term

therapy.

INPATIENT

Post Anesthesia Care Unit

(PACU)

The Post- Anesthesia Care

Unit, or more commonly

called the Recovery Room,

is a unit close in locaon

to the suite of Operang

Rooms where paents

that have just undergone

surgery are sent to be moni-

tored. The objecve of this

unit is to ensure the paent

remains stable before they

are admied to the proper

ward or unit within the

hospital.

INPATIENT

Operang Room (OR) Operang Rooms are usu-

ally in a suite- type sengwhere rooms are typically

designed in pods close to

each other. They are ulized

for major surgical proce-

dures that usually involve

unconscious sedaon and

anesthesia. ORs are all

sterile environments and

access is limited.

INPATIENT

Emergency Room (ER)

Urgency Room (UR)

Emergency Rooms or

Trauma Centers provide

for the emergent care and

treatment of paents with

life-threatening injuries or

crical medical condions

that are unstable. Many

also have a special secon,

somemes called Fast-

Track. Fast-Track provides

care for minor acute illnessand injuries. The paents

who are placed here for

treatment usually could not

get a same-day appoint-

ment with their Primary

Care Provider, or they do

not have medical insurance.

A UR is considered a step

below the ER and handles

cases on an unscheduled

walk-in basis. These facili-

es treat paents that may

require immediate care but

the maer is not serious

enough to warrant a visit to

an ER.

INPATIENT

Plasc Surgery This specialty provides a

variety of care either in a

hospital seng or in an

outpaent clinic. Some of

the services provided are

reconstrucve surgery,

liposucon, face-lis, breast

augmentaons and post-

burn paent skin graing to

name a few.

OUTPATIENT


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Ear Nose Throat (ENT) Paents are treated for

either surgical or medical

condions involving the

upper respiratory system.

These specialists are called

Otolaryngologists. They

provide a variety of ser-

vices from outpaent minor

chronic condions up to

and including surgery.

OUTPATIENT

RESPIRATORY THERAPY/PULMONOLOGY

This area of medicineincludes the care, diagno-

sis and treatment for all

diseases and condions

concerning the lungs. These

specialists primarily serve

in a hospital seng, but

some Respiratory Therapy

Specialists and Technicians

can also provide treatments

in a home-care seng, or in

skilled nursing facilies.

OUTPATIENT

PHYSICAL/

OCCUPATIONAL THERAPY

These two speciales are

interlinked to a certain

degree. Both Physical and

Occupaonal Therapistsprovide rehabilitave care

for paents who have suf-

fered from strokes, spinal

cord injuries, traum ac am-

putaons, or injuries that

do not allow these patents

full use of their extremies,

or loss of vision, hearing or

speech. The main goal in

this specialty is to return

as much funcon back to

the paent as possible. This

usually includes long-term

therapy in an outpaent

seng.

OUTPATIENT

AMBULATORY/SAME DAY

SURGERY

These outpaent clinics

provide minor surgical

procedures that do not

require general anesthesia.

As the name implies, these

paents are treated and

released within the same

day. Uncomplicated follow-

ups occur on an outpaent

basis as well.

OUTPATIENT

RADIOLOGY This supporve area ofmedicine provides imagin-

ing studies which aid the

physician in the diagnosis

of illness and disease.

These tests include X-

rays, Magnec Resonance

Imaging (MRIs), Computer

Tomography (CT) Scans and

Positron-Emission Tomogra-

phy (PETs) to name a few.

These tests can be com-

pleted in both inpaent and

outpaent environments.

OUTPATIENT

LABORATORY This supporve clinic

provides for the collec-on, analysis, and results

of a multude of urine,

blood and other body uids

test that are ordered by a

physician. Laboratory ser-

vices can be provided in a

hospital, emergency room,

or stand alone outpaent

clinics. These tests also aid

the physician in properly

diagnosing diseases.

OUTPATIENT

OPTHALMOLOGY This branch of medicine

deals with condions,

injuries and diseases of the

eye. Opthalmologists can

prescribe medicaon and

perform surgical procedures

on the eye, as well as, con-

duct various types of visual

screenings.

OUTPATIENT


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DERMATOLOGY This medical specialty

provides diagnosis and

treatment of condions

pertaining to the skin and

accessory organs, which

include the hair and nails.

Dermatologists usually work

in an outpaent seng.

OUTPATIENT

NUCLEAR MEDICINE Typically found within a

hospital seng, this spe-

cialty involves the injeconof radioacve isotopes into

a paent as part of an imag-

ing study, or to ascertain

structural funcon of an or-

gan. Strict guidelines must

be followed when dealing

with radioacve material .

OUTPATIENT

CARDIOVASCULAR Cardiovascular services that

are frequently oered as

an outpaent can be quite

varied. They may include

monitoring and control of

hypertension, most oen

through medicaon, pace-

maker monitoring, and lipidcontrol through medicaon.

This may also involve ongo-

ing rehabilitave services

aer a cardiac and Vascular

Tesng, EKGs, Echocardio-

grams, Event Monitor, Holt-

er Monitor, Stress tesng

(Includes Stress Echo and

Exercise Tolerance Tests),

and Vascular Ultrasound.

OUTPATIENT

Module 1 UNIT 3Code of Conduct

Communicang in the medical eld can be dicult, if you are not prepared. Al-

though the average American reads and speaks on an 8th or 10th grade level, the

medical professional has had 14-20 years of educaon. They oen speak using

medical jargon, which allows them to be concise and precise as they communi-

cate. Though extremely educated in their eld of experse, you may be working

with non-IT professionals. Time is crical i n this eld and concise, professionalcommunicaon is essenal.

Every profession has its own jargon and we oen forget to change our vocabulary

as we talk with those outside of our eld of experse. It is a team eort to com-

municate, as the speaker must ensure that they are not only heard, but under-

stood. However, it is also the listeners responsibility to indicate what theyheard

and did not understand. Learning some of the basic medical terminology and the

roles of the dierent medical professionals will make working within the medical

eld easier and you more ecient.

Adapng procedural behavior to dierent situaons

and environments

There are a large variety of medical environments, oen within the same facility.

Some have relaxed standards enabling you to work with lile change. While others

may have strict standards which will restrict your movements and require Personal

Protecve Equipment (PPE) as you work


17/26



Examples of such environments:

Imaging rooms - if the units are acve you may be exposed to radiaon

from x-rays or computer tomography (CT) scans. In contrast, a magnec

resonance imaging (MRI) uses a strong magnec eld, which will not

only aract metallic items, but deacvate any cards that use data strips

such as credit cards, or security badges.

Procedural room - a variety of procedures may take place such as,

sterile dressings, suture removal, minor surgical procedures (removal

of cysts, drainage of abscesses, or scar revision), gynecological proce-

dures, catheterizaons or applicaons of plaster casts.

Recovery room - paents arrive just out of surgery, and although not

in a sterile environment, the patents are sll in a precarious condion.

They are being monitored constantly for signs of danger.

Examinaon room - general room to talk with paents and to perform

non-invasive procedures.

Float room also referred to as a prep room, temp room, or hold -

ing bay this room consists of an area that is used to temporarily house

paents in transion between their paent room and another locaon.

One example is aer tests or surgeries.

Emergency room - The emergency medical department (EMD) is at

mes almost a whole hospital environment in itself. There may be x-rays, minor surgical procedures, cardiac procedures, laboratory proce-

dures, and general exams being conducted at the same me. Paents

are oen in pain and may be dying. The sta will be hurried using quick

precise movements to get as many paents seen and treated as soon

as possible.

Adapng social behavior based on sensivity of the

environment.

Entering the medical environment you may have to adapt your behavior to those

around you. Paents not only show up to receive general or emergency medical

care, but they may also be afraid for themselves or their family. Their future may

seem empty, without hope. In the Emergency Medical Departments (EMD) you

may be exposed to those who have just experienced extreme violence, such as

trauma, rape or child/spouse abuse. Your prejudices must be le at the door, as

you must always present yourself in a professional manner.

The need to follow medical precauonary guidelines.

The medical environment has many dangers not only for the paents, who may be

suscepble to disease, but also for those who may be exposed to their diseases.

You must look and ask about precauons as you enter an area.

Some of the precauons may include:

Universal Precauons, precauons designed to prevent the transmis-

sion of blood-borne diseases. Universal Precauons include specic

recommendaons for use of gloves, gowns, masks, and protecveeyewear when possible contact with blood or body secreons contain-

ing blood is ancipated.

Airborne precauons are used when a paent has a lung or throat in -

fecon or virus, such as chicken pox or tuberculosis that can be spread

via ny droplets in the air. The precauon that may be taken is called

airborne isolaon. This means the room will have negave air pres-

sure. When the door to the hospital room is open, air ows into room

but wont ow out into the hall. There will be a sign on the room door

alerng individuals to the situaon. You will need to clean your hands

when entering and exing the paents room. You should also conrm

that you have been vaccinated or have had the paents disease that

would have helped you to develop immunity.

Contact precauons are used when harmful germs can spread through

paent touch or the paent environment. There will be a sign on the

room door to alert individuals and advise of any required acons. You

will need to clean your hands when entering and exing the paents

room. Avoid contact with dressings, tubes, bed sheets and other items

the paent may touch.

Droplet precauons are used when the paent may have germs in

their lungs or throat, such as those caused by the u that can spread

by droplets from the mouth or nose when they speak, sneeze or cough.

These germ droplets can also infect people who touch the surfaces

around the paent. There will be a sign on the room door to alert

individuals. You will need to clean your hands when entering and exit-

ing the paents room, and perhaps wear a mask and eye protecon

before entering the room.

In any medical environment you have to connually wash your hands to avoid thespread of disease.

The following steps should be adhered:


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Hand Cleaning Standards

When cleaning hands with soap and water:

Wet hands with warm water.

Dispense one measure of soap into palm.

Lather by rubbing hands together for 15 seconds,

covering all surfaces of hands and ngers.

Rinse hands thoroughly.

Dry hands with paper towel.

Use a paper towel to turn o faucet.

Discard the paper towel in the trash container.

When cleaning hands with alcohol gel:

Dispense one measure of gel into palm of one dry hand.

Rub hands together covering all surfaces of hands and ngers unl dry,

about 15 to 20 seconds.

Conform to requirements set forth by the project manager:

You should always conform to all specied requirements as you begin a project.

You may be tasked to work in an environment that requires precauons, or to

work around scheduled mes when specic areas are not in use by paents or sta.

Module 1 UNIT 4Basic Clinical Terms

During your me in the medical facility you may hear various medical terms.

Although you may not be directly aected, it may require the aenon of the sta

around you.

Some common medical terms may be:

Medical imaging Images of body parts, ssues, or organs, which are used to

make clinical diagnosis. Imaging i ncludes not only x-rays, magnec resonance

imaging (MRI), positron-emission tomography (PET), and ultrasound, but other

studies as well.

Primary Care Physician (PCP) - A Physician, Physician Assistant, or Nurse Praco-

ner is usually the rst contact for a person with an undiagnosed health problem.

Typically, the PCP has specialized in family or general pracce medicine. They are

the gatekeeper for admission to the insurance companys system. HMO paents

must see their PCP and get a referral prior to going to a medical specialist.

STAT - Comes from the Lan word stam which means immediately. In the medi -

cal world it is said and wrien when something is urgent and needs to be done in

a rush.

Acuity - Sharpness or clarity of vision or of percepon.

Code Blue/Rapid Response - A slang term used by medical sta to refer to a pa -

ent in cardiopulmonary arrest. A team of trained providers (called a code team)

rush to a specic locaon with specialized medical drugs and equipment and ini-

ate immediate resuscitave eorts. They are also called a rapid response team.


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Some facilies may use other terms to avoid alerng paents, such as Dr. Blue.

Hospital Trauma Level - Hospitals have designated trauma levels based on the

emergency services they provide:

Level I - A Level I Trauma Center provides the highest level of surgical

care to trauma paents. It has a full range of specialists and equipment

available 24 hours a day. The Level I center will also have programs of

research and educaon.

Level II - A Level II trauma center works in collaboraon with a Level I

center. It provides comprehensive trauma care and supplements the

clinical experse of a Level I instuon. It provides 24-hour availability

of all essenal speciales, personnel, and equipment.

Level III - A Level III trauma center does not have the full availability of

specialists, but does have resources for emergency resuscitaon,

surgery, and intensive care of most trauma paents.

Level IV - A Level IV provides inial evaluaon, stabilizaon, diagnosc

capabilies, and transfer to a higher level of care.

Level V - Provides inial evaluaon, stabilizaon, diagnosc capabili-

es, and transfer to a higher level of care. It may not be open 24 hours

daily, but it will have an aer-hours trauma-response protocol.

Other schedules or levels used in healthcare involve the levels of controlledsubstances. There are several drugs that are not accepted for medical use and are

unsafe. By comparison, there are drugs used for medical treatment with certain

restricons that may be abused like drugs with no medical use. Drugs with a po -

tenal for abuse are controlled by healthcare facilies including pharmacies. The

use of e-prescribing ensures correct controlled substance regimens are correctly

followed. Best pracces for eMAR (Electronic Medicaon Administraon Records)

may include the pharmacy being able to track inventory of controlled substances

through the use of wristband vericaon. This may include data input into an Elec-

tronic Health record (EHR) via a scanned barcode on a paents wristband.

Controlled Substance Levels- Drugs and other substances that are considered

controlled substances under the Controlled Substance Act are divided into ve

schedules.

Schedule I Controlled Substances - Substances in this schedule have

a high potenal for abuse, have no currently accepted medical use in

treatment in the United States, and there is a lack of accepted safety

for use of the drug or other substance under medical supervision.

Schedule II Controlled Substances - Substances in this schedule have

a high potenal for abuse which may lead to severe psychological or

physical dependence.

Schedule III Controlled Substances - Substances in this schedule have

a potenal for abuse less than substances in schedules I or II and abuse

may lead to moderate or low physical dependence or high psychologi-

cal dependence.

Schedule IV Controlled Substances - Substances in this schedule have a

low potenal for abuse relave to substances in schedule III.

Schedule V Controlled Substances - Substances in this schedule have a

low potenal for abuse relave to substances listed in schedule IV and

consist primarily of preparaons containing limited quanes of certain

narcocs.

EMR (Electronic Medical Record)/EHR (Electronic Health Record) - The EMR is an

electronic record of health-related informaon on a paent that is created by asingle medical organizaon by providers who are involved in the i ndividuals health

and care. This is usually iniated by a specialty clinic that is not responsible for the

total care of the paent. T he EHR is an electronic record of health-related infor-

maon on a paent that is created and gathered from more than one health care

organizaon and is managed and consulted by a physician/sta involved in the

paents overall health and care.

St d t M l StM d l 1 UNIT 5 M d l 1 UNIT 5


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Module 1 UNIT 5Medical Roles

Healthcare instuons are responsible for maintaining paent records in a safe

and secure manner.

Today, paperless, digital and computerized systems for maintaining paent data

are available and have made the medical industry more ecient. As menoned

in the prior unit, the automated system is called Electronic Medical Record (EMR)

system. Pung an EMR system into operaon is a complex, expensive investment

that has created a demand for Healthcare IT professionals and accounts for a

growing segment of the healthcare workforce.

Implemenng an Electronic Health Record (EHR) or Electronic Medical Record

(EMR) system inherently changes the way in which informaon is managed. This

includes, but is not limited to, the pracces for managing the security of EHR data.

Access roles and responsibilies are assigned to support the Health Insurance Por-

tability and Accountability Act (HIPPA) regulaons. When implemenng an EHR or

EMR system a team should be formed to evaluate a facilitys data security needs,

determine the best soluons and set security requirements. EHR and EMR systems

frequently have Role Based Access Control (RBAC) with predened proles that

can be assigned. RBACs are designed by the level of access that role needs to be

able to appropriately perform their dues.

Here is a typical series of paent encounters that involve an EMR system and the

necessity for access roles.

The paent checks in at the front desk by an administrator at Britannia Hospital

who has access only to appointment and demographic informaon.

When the paent is moved to the examinaon room, the nurse has

security access to record the paents vital health i nformaon (weight,

blood pressure and temperature) and to conrm his medicaon list.

The aending Physician, then meets with the paent diagnosing the

medical problem and issuing orders to the lab.

The EMR system allows for each paent encounter to be recorded and to pro-

vide each medical provider the access he/she needs to perform their role, while

protecng the condenali ty of the paent. In the example above, the three

individuals providing a service to this paent all have the appropriate access level

of authencaon that parallels their role of service.

Medical facilies should evaluate how a paents informaon is stored within their

system and determine which sta members have access to paent data and how

much data they should be allowed to handle. Access levels should be assigned to

allow sta to work eciently and producvely, while maintaining the highest level

of security.

For example, Clinical roles in an environment include:

Medical Doctor (MD)

Registered Nurse (RN)

Physicians Assistant (PA)



21/26



Dental Assistant (DA)

Paent Care Technician (PCT)

Medical Assistant (MA)

Licensed Praccal Nurse (LPN)

While the above clinical roles need access to paent medical data, medical oce

sta, consultants and business clients would have a more restricted access to the

EHR or EMR data, which would be dependent upon their specic role.

Medical Oce Sta roles would include:

Nursing Unit Clerk (NUC)

Unit Administrator (UA)

Project Manager (PM)

Oce Manager

Sta

If healthcare facilies take the appropriate steps to safeguard EHR and EMRs,

the threat of security breaches and resulng HIPPA penales can be minimized

while providing paents a level of trust. It is imperave that appropriate access

roles and responsibilies be established. Most EMR systems provide a record of

accountabil ity. Should any suspicious acvity be detected, a detailed record of

data access and modicaon to paent records can be viewed. The accountability

reports play a vital role in ongoing security management.

Module 1 UNIT 6Medical Interfaces Fundamentals

Regular and advanced devices are used within the healthcare seng to provide

analysis and measurements during an encounter. Informaon from these devices

ows from the local device to a workstaon. This device may be ed back to a

module that accesses and updates an EHR within an EMR system. Troubleshoong

experse of interfaces, devices, advanced devices, and the general understand -

ing of a workow such as an encounter is the key to a successful outcome for the

Healthcare IT Technician. The most common interfaces are listed as follows:

HL7 | Health Level 7 | Most common Applicaon Interface

ePrescribing

CCD

CCR

ICD10

CPT

SNOWMED

NDCID

PACS

E/M Codes

In review of the 10 most common applicaon interfaces,

HL7 - Health Level Seven Internaonal (HL7) is the global authority on standards

for interoperability of health informaon technology with members in over 55

countries. Hospitals and other healthcare provider organizaons typically have

many dierent computer systems used for everything from billing records to

paent tracking. All of these systems should communicate with each other (or

interface) when they receive new informaon, but not all do so. HL7 species

a number of exible standards, guidelines, and methodologies by which various

healthcare systems can communicate with each other. Such guidelines or data

standards are a set of rules that allow informaon to be shared and processed in a

uniform and consistent manner. These data standards are meant to allow health-

care organizaons to easily share clinical informaon. HL7 is derived from the OSI

model Layer 7 (described in Module 3, Unit 1), where applicaons communicate

and communicate across the enterprise.

E-Prescribing denes a new feature for the prescribers ability to electronically

send an accurate prescripon to a pharmacy from a physician. This allows for ane-prescribing plaorm in enhancing paent safety. E-prescribing is one of the key

iniaves to expedite the adopon of electronic medical records and build a na-

onal electronic health informaon infrastructure in the United States.

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For example, most electronic medical record systems include e-prescribing fea-

tures. The workow may be as follows:

1. Prescriber Two-Factor Authencaon

-Something you know, and something you have, as described in Module 8,

Unit 1

2. Paent Lookup

3. Drug and Regimen selecon

4. Allergy and drug reacons noted

5. Selecon of alternave drugs

6. Pharmacy Selecon

7. Electronic transfer

8. Paent goes to get lled prescripon

CCD - Connuity of Care Document is the preferred interface standard for com -

municaon between EMR soware systems and paent portal systems. This is

because the CCD standard oers greater scalability in comparison to the CCR stan-

dard, as it can grow and wil l accommodate greater amounts of work. Medical Web

Experts has outstanding experience with this technology. The CCD is a joint eortof HL7 and ASTM to foster interoperability of clinical data to allow physicians to

send electronic medical informaon to other providers. The CCD is a CDA imple-

mentaon of ASTMs Connuity of Care Record (CCR). It is intended as an alternate

implementaon to the HL7 Clinical Document Architecture. The CCD represents

a complete implementaon of CCR, combining the best of HL7 technologies with

the richness of CCRs clinical data representaon, and does not disrupt the exisng

data ows in payer, provider, or pharmacy organizaons. The CCD is an XML-based

standard that species the structure and encoding of a paent summary clinical

document. It provides a snapshot in me, constraining a summary of the per -

nent clinical, demographic, and administrave data for a specic paent.

CCR - The Connuity of Care Record, or CCR, is a standard developed by ASTM

Internaonal - a gl obal leader in the creaon of consensus standards. Because a

CCR document is slightly limited in its ability to become a highly-scalable soluon

for interfacing two systems, the Connuity of Care Document (or CCD) was invent -

ed to link ASTMs CCR with the HL7s Clinical Documentaon Architecture.

ICD-10 - The Internaonal Stascal Classicaon of Diseases and Related Health

Problems, 10th Revision is a medical classicaon list for the coding of diseases,

signs and symptoms, abnormal ndings, complaints, social circumstances, and

external causes of injury or diseases. It is maintained by the World Health Organi-

zaon (WHO).

CPT - (Current Procedural Terminology) codes are numbers assigned to every task

and service a medical praconer may provide to a paent including medical,

surgical and diagnosc services. They are then used by insurers to determine the

amount of reimbursement that a praconer will receive by an insurer. Since ev -

eryone uses the same codes to mean the same thing, they ensure uniformity. CPT

codes are developed, maintained and copyrighted by the AMA (American Medical

Associaon.) As the pracce of health care changes, new codes are developed for

new services, current codes may be revised, and old, unused codes are discarded.

Thousands of codes are in use, and they are updated annually.

SNOMED CT - (Systemazed Nomenclature of Medicine), is a systemacally

organized computerized collecon of medical terminology covering most areas

of clinical informaon such as diseases, ndings, procedures, microorganisms,

substances, etc. allowing a consistent way to index, store, retrieve, and aggregate

clinical data across speciales and sites of care. It also helps organizing the content

of medical records, reducing the variability in the way data is captured, encoded

and used for clinical care of paents and research. It is a structured collecon of

medical terms that are used internaonally for recording clinical informaon and

are coded in order to be computer processed. It covers areas such as diseases,

symptoms, operaons, treatments, devices and drugs. SNOMED CT is considered

by some to be the most comprehensive, mullingual clinical healthcare terminol-

ogy in the world. It provides for consistent informaon interchange and is funda-

mental to an interoperable electronic health record. It can be used to record the

clinical details of i ndividuals in electronic paent records and support applicaonfunconality such as informed decision making, linkage to c linical care pathways

and knowledge resources, shared care plans and as such support long term paent

care. It was originally created by the College of American Pathologists (CAP) and,

as of April 2007, owned, m

it healthcare manual 020612 sample

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