Answering Case-Based Exam Questions Flashcards
What is the patient medical record (PMR)?
The patient medical record (PMR) provides complete documentation of a patient’s medical history at a particular institution
*can be referred to as the “medical record” or the “patient chart”
How do EHRs improve accuracy and efficiency?
EHR provides current and previous lab results (by selecting a date range that can go back years in time) which are used to determine if this is a new or an old finding and what recent workup has been completed
What are the advantages of electronic health records?
EHRs allow providers to have immediate access to information when they are off-site. Procedures with results recorded on paper or faxed records from another facility can be quickly scanned into the EHR
What are the advantages of the EHR being linked to Computerized Prescriber Order Entry (CPOE) and electronic prescribing?
- The problem of illegible handwriting is eliminated
- The CPOE system can be designed to present only formulary drugs with proper dosing as options
What are clinical decision support tools?
Clinical decision support (CDS) tools can be built into the order entry process which include order sets, pathways, limited drop down menus that reflect the preferred drug/s, drug interaction and dose checking alerts
What is HIPAA?
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires security protections for all individually identifiable health information, called protected health information (PHI) and these protections apply to both paper records and electronic records
How are EHRs HIPAA protected?
For electronic records, access is limited with PINs and passwords. The information is encrypted and there is an audit trail to track access
*All personnel using the EHR are responsible for security and education on security must be continual
What are the first additions to the patient medical record?
The first addition to the patient medical record are the patient’s demographic data (including insurance information), admission sheet, a service agreement form, a page describing the patient’s rights and an advanced directive
*Allergies may be here or listed in a separate area of the chart
What is an advanced directive?
An advance directive documents the patient’s wishes concerning medical treatment if they are unable to make decisions on their own behalf
Why do religious beliefs need to be documented in the PMR?
Certain religious groups will refuse blood transfusions and blood products, which will need to be documented in the PMR
What are some other forms or sections that can be in a PMR?
Other forms or sections in the PMR include progress notes, the vital signs record, laboratory tests, monitoring records used for some medications, medication administration records and procedures records, including the diagnostic and operating room records
What should you avoid when documenting information in the PMR?
When documenting information in the PMR, it is important to avoid abbreviations that could be interpreted to mean something else
Why do interventions require documentation?
Interventions require documentation for reimbursement since the quality of care is (increasingly) tied to the payment
*Departments of pharmacy should have policies in place that describe the authority of pharmacists to document in the PMR, what activities will be documented and the proper format for documentation
What are examples of activities that pharmacists document in the PMR?
Patient counseling, medication histories, consultations and dosage adjustments
How do the Centers for Medicare and Medicaid Services play a role in reimbursement?
CMS has penalties for poor care and incentives for quality care
What are two areas in which the CMS gives steep penalties?
Two areas in which the penalties are steep are the rate of hospital-acquired infections and the hospital’s readmission rate. These measures are chosen because they are expensive and are often, but not always, avoidable.
What are the Joint commission, the Pharmacy Quality Alliance (PQA) and the Agency for Healthcare Research and Quality (AHRQ) involved in?
Setting the criteria to measure the quality of care
What are some specific goals for PQA quality measurements?
Specific goals include increasing adherence, avoiding unnecessary or unsafe medications and increasing the use of medications indicated for certain conditions
What is Medicare and describe the different parts of Medicare?
Medicare is the federal health insurance program for people > 65 years old, < 65 with disability and all ages with end stage renal disease (ESRD). The prescription drug benefit under Medicare is called Part D. Part A covers the hospital visit and Part B covers medical costs, such as doctor visits and some vaccines
What is Medicaid?
Medicaid provides health insurance for all ages with very low income (< 133% of the federal poverty level). Medicaid is a federal and state program and a senior who qualifies for both Medicare and Medicaid has “dual coverage”
