Electronic Health & Medical Records Flashcards
What is conditioning?
- grouping related papers together
- removing paper clips and stables
- fixing damaged records
What is releasing?
marking the form to be filed
- provider’s initials
- stamped
What is indexing and coding?
determining where to place the file in the record
What is sorting?
ordering papers in a filing structure
- placing files in specific groups
What is sorting and filing?
securing documents permanently in the file
What is the most common way to organize files?
alphabetic
- last name, first name, middle initial
What are the benefits of numeric filing?
allows for unlimited expansion
What is an example of subject filing?
- lab results
- radiology reports
What is EMR?
electronic medical record
- digital charts to be used
What is EHR?
electronic health record
- includes EMR and other information to be used between facilities
What is PHR?
personal health record
- access controlled solely by patient
- data entered by the patient
How is PHR different than EHR?
- not legal documents
- not entered by healthcare professionals
- can’t be disclosed without patient’s written permission
- contain treatment information from all providers
What are the key differences between EMR and EHR?
EMR:
- only one provider
- can’t be shared between providers
- patient info doesn’t move outside one healthcare setting
- used for diagnosis and treatment only
What are some advantages of EHR programs?
- fewer lost medical records
- ease of chart access for multiple users
- decreased duplication of test orders
- greatly decreased storage needs
What does addendum mean?
corrections on EHR
What is history of present illness also known as?
chief complaint
What is the release of information form?
HIPAA form
- allows practice to share patient information
What is the consent to treat form for?
gives the physician permission to treat a child
Who can authorize medical forms?
- patient
- minor’s parent or legal guardian
- power of attorney
