5 + 6 Patient Records and Documentation

Question 1

What is an electronic health record (EHR)?

Answer 1

EHR is a system that makes up the secure and private lifetime record of someone’s health and health care history. It contains lab results, medication profiles, clinical reports, discharge summaries, diagnostic images etc. “person-centric health record, which can be used by many approved health care providers or health care organizations”.

In ontario is it called connecting ontario.

Question 2

What is an electronic medical record? (EMR)

Answer 2

A computer-based medical record that is SPECIFIC TO ONE CLINICIAN’S PRACTICE (as opposed to the EHR that is across many organizations and providers). Sometimes it can incomplete because it is only for one practice. “provider-centric OR health organization-centric”. For example, meditech is used in hospitals.

Question 3

What is patient health record (PHR)? What is hospital information system (HIS)?

Answer 3

PHR = often integrated with EMR and EHR, it is a complete or partial health record that is under the custodianship of the person that holds the health information over their lifetime.

HIS = computer-based medical record specific to the inpatient setting in the organization. (i.e. hospitals have HIS used in inpatient settings).
*HIS can be a type of EMR; if it is widely linked outside of the hospital, then it is an EHR, but if it is only used in the hospital then it is in EMR.

Question 4

What is interoperability?

Answer 4

The ability of 2+ systems to exchange information or function together (bidirectional flow of information).

Interoperability can be hard to achieve bc everyone has different software that doesn’t connect with that of the hospital or the pharmacy etc.

Question 5

What are some of the benefits of having digital records?

Answer 5

• improved communication
• more easily accessible information
• improved patient safety
• more efficient
• more convenient
• decreased errors
• improved decision making

Question 6

What are some of the challenges to digital records?

Answer 6

• cost (having to convert paper records to digital records)
• user reluctance
• disruption to workflow (having to modify space to accommodate the new workflow)
• perceived vulnerability to security breaches
• sharing of personal information across provinces (hard to do bc the softwares are all different)

Question 7

What is the aEHR? why is it important? what are the sections?

Answer 7

academic electronic health record, it is important because electronic health and medical records are used in most health care settings and they aim to prepare students for what we will see in practice.

1. patient profile (demographics, allergies, history, etc)
2. current visit (details, vital signs, fluid balance, assessments, non-medication orders, med orders, billing etc)
3. patient chart (progress notes, Interprofessional plan of care, reports and documents)
4. external resources (ex CPS)

Question 8

What is a pharmacy practice management system? (PPMS)

Answer 8

System on which all community pharmacies in Canada record medications and related information (it doesn’t have to be the same system for everyone, but they have similar functionality).

Examples would be Kroll, pharmaclick rx, etc.

PPMS will have drug interactions programs embedded in the softwares and the processing of a prescription will result in dispensing record, labels, receipt, aux labels, information pamphlets etc (all of it is built into the software).

There is a patient fields, prescriber field, drug field, prescription field.

PPMS can also be used to order products and manage inventory, give detailed medication product information, and for electronic billing of insurance.

Question 9

How can the data in PPMS be used?

Answer 9

Internally - by pharmacy staff (drug plan details, medications owing etc)

Externally - by health care providers. Individuals who bill their medications through ODB will have that information transmitter to an electronic health record/provincial drug information system (DHDR in Connecting Ontario- which will have most of the information, just doesnt have the sig). Patients also have the right to mask certain medications from their record.

Question 10

What is Drug Information System? (DIS)

Answer 10

An electronic repository of medication and prescription data held at the provincial level. In Ontario it is DHDR. Pharmacists can write in DIS and other professions can only read it. Information from all the drug stores in ontario are transmitted to the drug health system for ODB patients.

Question 11

What constitutes personal health information?

Answer 11

any recorded information about a person OTHER THAN THEIR CONTACT INFORMATION. (DOB, sex, ethnic origin, blood type etc).

Question 12

What is the different between privacy, security, and confidentiality?

Answer 12

Privacy is the right to be free from intrusion and interruption (individuals have the right to determine when how and to what extent they share information).

Security is the preservation of confidentiality, integrity, and availability of personal health information.

confidentiality is the principle that information is not made available or disclosed to unauthorized individuals.
CONFIDENTIALITY IS NECESSARY BUT NOT SUFFICIENT FOR MAINTAINING PRIVACY.

Question 13

How is security of information achieved?

Answer 13

• planning and implementing maintenance of appropriate technology solutions
• managing physical space to ensure privacy during the provision of care
• managing the collection, access, disclosure of personal health information
• having health care providers be good custodians of information
• planning tech solutions
• managing physical space
• managing the collection and acceess
• HCP are good custodians of information

Question 14

Why is confidentiality important and what are some circumstances in which it is okay to disclose information without patient consent?

Answer 14

Confidentiality is important because it encourages patients to provide relevant information (if they trust you, they are more likely to provide the necessary information to ensure efficient and effective health care).

Circumstances for disclosure without patient consent include:

• emergency care (disclose to other HCP)
• threat (disclose to police when there is a threat of patient harming)
• communicable diseases
• child or spouse abuse
• subpoena/court order

Question 15

What are some consequences of confidentiality breach?

Answer 15

• sanctions from employer or regulatory body and legal consequences

Make sure to read carefully any consents regarding maintaining confidentiality of information

Question 16

What are the federal and provincial laws that are related to privacy?

Answer 16

PIPEDA (federal) and PHIPA (provincial).

PIPEDA - applies to personal information in the federally regulated private sector and information that crosses provincial and national borders. Organizations need expressed consent for collection and use of the information. Personal information can ONLY BE USED FOR THE PURPOSE FOR WHICH IT WAS COLLECTED.

PHIPA only applies to the PHI that is collected used and disclosed by health information custodians.

Question 17

What is the difference between expressed consent and implied consent?

Answer 17

Expressed consent the voluntary agreement with what is being done and does not require any inference on the part of the patient.

Implies consent is the voluntary agreement with what is being done which can be reasonably determined through the actions or inactions of the person. This can be done within the circle of care.

Question 18

What is the circle of care?

Answer 18

Circle of care is a term used to describe the ability of certain health information custodians to assume someone’s IMPLIED CONSENT to collect, use, or disclose personal health information for the delivery of health care.

It is not defined in PHIPA.

There are 6 conditions that must be met to assume consent is implied.

Question 19

What are the 6 conditions that must be met to assume that consent is implied in the circle of care?

Answer 19

1. health information custodian has to be entitled to rely on assumed implied consent.
2. the health information must have been received from the individual, their substitute decision maker, or another health information custodian
3. the health information custodian receiving the information must have gotten it for the purpose of providing or assisting in the provision of care to the individual.
4. the purpose of the collection is for the provision of health care or assisting the provision of health care to the individual.
5. disclosure of personal health information must be done to another health information custodian.
6. the health information custodian that receives the information must not be aware that the individual has expressly withheld or withdrawn their consent. (i.e. to use the information you cannot be aware if they have withdrawn their consent, or else you cannot do it).

PHIPA permits a health information custodian to disclose health information without consent if there are reasonable grounds to believe that it is necessary to eliminate or reduce risk to a group of people. (i.e. communicable diseases)

Question 20

Documentation Guidelines - why and when do pharmacists document?

Answer 20

Pharmacists documents to show accountability and responsibility for their actions, demonstrate medication therapy management expertise and professional judgement, and show inter and intra professional delivery of patient care.

Good documentation should be done currently and is complete and organized.

Documentation should be done during patient encounter, education, discussion, recommendations, adverse reactions etc.

Question 21

What do CC, HPI, PMH stand for on admission notes on patient chart?

Answer 21

CC = chief complaint, reason the patient sought care.

HPI = history of present illness (symptoms)

PMH = past medication history .

Question 22

Documentation Formats: why do these stand for? SOAP, FARM, DRP, DAP, DDAP

Answer 22

soap = subjective, objective, assessment, plan

farm = findings, assessments, recommendations, monitoring

drp= drug-related problem, rationale, plan

dap = data, assessment, plan

ddap= drug-related problem, data, assessment, plan

Question 23

What is a SOAP note used for?

Answer 23

To document patient’s continued care as each complaint or problem is addressed.

S = subjective, what the patient describes

O = objective, observable information (something you can measure)

A = assessment (progress and evaluation of plan’s effectiveness and new found problem

P = plan (decision to proceed or change plan)

SOAP notes are used by ALL health care professionals, one of several documentation formats.