Electronic Health record Flashcards
T OR F
EHR is not the same as that developed in other countries
TRUE
T OR F
EHR is a major step and has only been successfully
achieved in a few healthcare institutions to date.
TRUE
We should focus on encouraging them to:
Improve accuracy and quality of data recorded in a health record
Enhance health practitioners’ access to a patient’s health information
Improve the quality care
Improve the efficiency of health record service
Contain healthcare costs
T OR F
A paperless environment will come
TRUE
T OR F
If identified problems are not addressed and remedied prior
to introducing an EHR system, merely automating health
record content and procedures may perpetuate deficiencies
and not meet the EHR goals of the institution or the country.
TRUE
“Current problems identified in healthcare documentation,
as well as ___ and ____ must be
addressed, and ______introduced before
a successful change can be implemented.”
“Current problems identified in healthcare documentation,
as well as privacy and confidentiality issues must be
addressed, and quality control measures introduced before
a successful change can be implemented.”
T OR F
Although the introduction of a fully electronic health record
system may seem far off in many healthcare institutions or
countries, they are being introduced rapidly in others and
there is no doubt that the future of health information
management lies with automation and the automatic
transmission of information required for patient
management at all levels of healthcare
TRUE
What are other terms used to refer to EHR
Automated Health Record [Electronic Health Records
Manual for Developing Countries 11 Records (AHR)]
Electronic Medical Record (EMR)
Computer-based Patient Record (CPR)
Electronic Health Record (EHR)
An electronic record of health-related information on an individual that conforms to nationally recognized
interoperability standards and that can be created,
managed, and consulted by authorized clinicians and staff across more than one health care organization.
A. AHR
B. EMR
C. CPR
D. EHR
D. EHR
An electronic record of health-related information on an individual that conforms to nationally recognized
interoperability standards and that can be created,
managed, and consulted by authorized clinicians and staff across more than one health care organization.
A. AHR B. EMR C. CPR D. EHR E. PHR
D. EHR
Used to describe a collection of computer-stored images of
traditional health record documents
A. AHR B. EMR C. CPR D. EHR E. PHR
A. AHR
An electronic record of health-related information on an
individual that can be created, gathered, managed, and
consulted by authorized clinicians and staff in one
healthcare organization
A. AHR B. EMR C. CPR D. EHR E. PHR
B. EMR
Used to describe automated systems based on a document
imaging or systems which have been developed within a
medical practice or community health care.
A. AHR B. EMR C. CPR D. EHR E. PHR
B. EMR
Most of the focus in the early 1990s was on document
scanning onto optical disks. This addressed access, space,
and control problems related to paper-based records but did
not address data input/output at patient care level.
A. AHR B. EMR C. CPR D. EHR E. PHR
A. AHR
More simply stated, this type of a longitudinal electronic
health record could be defined as:
o Containing all personal health information belonging to
an individual
o Entered and accessed electronically by healthcare
providers over the person’s lifetime, and
o Extending beyond acute inpatient situations including
all ambulatory care settings at which the patient
receives care
A. AHR B. EMR C. CPR D. EHR E. PHR
D. EHR
Collection of health information for one patient linked by a
patient identifier
A. AHR B. EMR C. CPR D. EHR E. PHR
C. CPR
include as little as a single episode of care
for a patient or healthcare information over an extended
period of time
A. AHR B. EMR C. CPR D. EHR E. PHR
C. CPR
An electronic record of health-related information on an
individual that conforms to nationally recognized
interoperability standards and that can be drawn from
multiple sources while being managed, shared, and controlled by the individual
A. AHR B. EMR C. CPR D. EHR E. PHR
E. PHR
Developed within a medical practice or health center
A. AHR B. EMR C. CPR D. EHR E. PHR
B. EMR
Although this form of a computer-based patient record was
implemented in a variety of settings the focus on
exchanging health information was limited to inpatient
facilities.
A. AHR B. EMR C. CPR D. EHR E. PHR
C. CPR
• Digital version of paper charts
• Contains medical and treatment history of patients in one
practice or organization
• However, the information of EMRs does not travel easily out
of the practice
EMR
Focus on the total health of the patient
o Going beyond standard clinical data collected in the
provider’s office or during episodes of care and
inclusive of a broader view on a patient’s care
o Designed to reach out beyond the health organization
that originally collects and compiles the information
oThey are built to share information with other health
care providers and organizations such as laboratories
and specialists
EHR
are able to electronically collect and store
patient data to supply that information to the providers and
requests, permit clinicians to enter orders directly into the
authorized provider order entry system, and advise
healthcare practitioners in providing decisions to accord to
such as reminders, alerts, and access to the latest
research findings or appropriate evidence based
guidelines.
A. EMR
B. EHR
C. EMR and EHR
C. EMR and EHR
refers to organizational systems that include at
least the 4 core functions
A. EMR
B. EHR
C. EMR and EHR
A. EMR
refers to systems that share information across
different organizations, perhaps through a regional health
information organization
A. EMR
B. EHR
C. EMR and EHR
B. EHR
T OR F
The decisions of probabilities with the EMR are more
robust than the digital version of the paper medical record.
TRUE
a major issue that should be
addressed before moving forward to automation
Unique patient identification
the backbone of an
effective and efficient health record system, whether
manual or electronic
Accurate patient identification
Other possible issues
Clinical data entry issues and lack of standard
terminology
a set of common standards for data
collection and is used to promote uniformity in
documentation, data processing and maintenance
data dictionary
what issue is seen in
• Clinical data standards are developed to ensure that data
collected in one hospital department or facility means the
same in another department or facility
Clinical data entry issues and lack of standard terminology
Resistance to computer technology and lack of computer literacy
Strong resistance to change by many healthcare
providers
High cost of computers and computer systems and funding limitations
Concern by providers as to whether information will be available on request
Concerns about privacy, confidentiality, and the quality and accuracy of electronically generated information
Quality of electronic healthcare information and
accuracy of data entries
Lack of staff with adequate knowledge of disease
classification systems
Manpower issues – lack of staff with adequate skills
Environmental Issues
Involvement of clinicians and hospital
administrators
T OR F
The lack of standard terminology could be a major
stumbling block to the successful introduction of an
electronic health record system
TRUE
T OR F
Successful implementation of an EHR will be dependent on
the computer skills of all healthcare professionals and other
staff. Although in today’s world many use computers,
particularly the Internet, some are still not proficient in
using computers as they do not routinely use computers
at work or at home.
TRUE
the main strategy to have in place
to help overcome such resistance ARE (3)
to have them involved
from the outset in discussions on the development and
implementation of an EHR
As well as being trained in the technology
they need to be involved in system selection and design.
Need to compare the current system costs plus
perceived costs for the new EHR system addresses what issue?
High cost of computer systems and funding limitation
T OR F
In EHR the information will
not only be readily available at all times
TRUE
- Information should always be readily available
- Information can be accessed more efficiently
Providers need to be assured that while the information will
not only be readily available at all times, they will be able to
access it more efficiently
In fact, the information will and should be more readily
available than in a manual system where medical records
are filed in an MRD which is not open 24-hours a day.
T OR F
In EHR the information will and should be more readily
available than in a manual system where medical records
are filed in an MRD which is not open 24-hours a day.
TRUE
The relevant legal issues should include _________ from electronic media on which it is stored. The durability of the electronic media must also be tested and documented.
retention
schedules and how information is to be retrieved from
T OR F
it is suggested that the quality of electronically
recorded data is better as there are measures in place, such
as edit checking, aimed at ensuring accuracy
TRUE
The characteristics of data quality include: (6)
Accuracy and validity of the original source data
Reliability
Completeness
Legibility
Currency and Timeliness
Accessibility
T OR F
All these characteristics are important in manual
record systems
FALSE
All these characteristics are important in both manual and
electronic record systems
Whatever the system, the quality of healthcare data is
crucial, not only for patient care, but also for monitoring the
healthcare services and the performance of the institution
coding training programs is extremely limited is under what issue
Lack of staff with adequate knowledge in disease classification systems
T OR F
Currently, there is more computer-assisted coding than
coding entirely by computer
TRUE
staff may be available but
their skills may not be adequate for the tasks expected of
them is under what issue
Manpower issues – Lack of staff with adequate skills
A major concern in many developing countries is an
available and reliable electrical wiring and supply of
electricity within the healthcare facility is under what issue
Environmental issue
T OR F
Another important environmental issue is the amount and
quality of available space needed for computers and
other equipment.
true
could be the most difficult of the non-technical issues to be addressed.
Willingness by healthcare providers to collaborate and
share data with other providers and also with the patient
Their specifications and input are important for their
acceptance of the system, especially issues relating to
ownership of the information is under what issue
Involvement of clinicians and hospital administrators
must be in place to
ensure against loss, destruction, tampering and
unauthorized use of electronic records.
safeguards
SAFEGUARDS
means for ongoing
monitoring and evaluation of the system to ensure that
all users adhere to the stated standards
A. Efficient back-up system available
B. Contingency plan
C. Securing workstations and password requirement
D. Access control to authorized persons only
E. Audit control
F. Administrative security requirements
G. Incident reporting and response mechanisms
H. Policies and procedures and workforce training
G. Incident reporting and response mechanisms
ensure that uses and disclosures
are made only as permitted or required by law
A. Efficient back-up system available
B. Contingency plan
C. Securing workstations and password requirement
D. Access control to authorized persons only
E. Audit control
F. Administrative security requirements
G. Incident reporting and response mechanisms
H. Policies and procedures and workforce training
H. Policies and procedures and workforce training
for disaster recovery need to be in
place in the case of an electrical breakdown or other emergency
A. Efficient back-up system available
B. Contingency plan
C. Securing workstations and password requirement
D. Access control to authorized persons only
E. Audit control
F. Administrative security requirements
G. Incident reporting and response mechanisms
H. Policies and procedures and workforce training
B. Contingency plan
where access may be monitored to
ensure only authorized persons use the system and to
identify when changes are made in the record
A. Efficient back-up system available
B. Contingency plan
C. Securing workstations and password requirement
D. Access control to authorized persons only
E. Audit control
F. Administrative security requirements
G. Incident reporting and response mechanisms
H. Policies and procedures and workforce training
E. Audit control
for all users. The passwords should be changed
regularly to maintain security
A. Efficient back-up system available
B. Contingency plan
C. Securing workstations and password requirement
D. Access control to authorized persons only
E. Audit control
F. Administrative security requirements
G. Incident reporting and response mechanisms
H. Policies and procedures and workforce training
C. Securing workstations and password requirement
ensure health records are available when needed for
patient care and other official purposes but may not be
accessed by unauthorized persons
A. Efficient back-up system available
B. Contingency plan
C. Securing workstations and password requirement
D. Access control to authorized persons only
E. Audit control
F. Administrative security requirements
G. Incident reporting and response mechanisms
H. Policies and procedures and workforce training
D. Access control to authorized persons only
for risk analysis processes and for management must also be in place
A. Efficient back-up system available
B. Contingency plan
C. Securing workstations and password requirement
D. Access control to authorized persons only
E. Audit control
F. Administrative security requirements
G. Incident reporting and response mechanisms
H. Policies and procedures and workforce training
F. Administrative security requirements
designated to perform clearance checks on
members of the workforce who will have regular
access to the system
information security officer
T OR F
it may be possible to implement a welldesigned EHR, but if potential issues and challenges have
not been addressed, and if users have not been involved in
the design or in the selection of the system, are not properly
trained, and/or are not supported by the healthcare
authorities, the system may not be used effectively and may
therefore fail to produce the anticipated outcome
TRUE
will provide immediate
access to data and enable processing that data in a variety
of ways to support both the decision making process by
health professionals for patient care and clinical and health
services research
EHR
The proposed electronic health record will cover the
following:
All personal health information about an individual,
entered electronically by healthcare providers at
the point of care over a person’s lifetime
Accessibility by healthcare providers and departments within the hospital from which the
patient has received care
Organization of information primarily to support
continuing, efficient and quality healthcare within
the healthcare facility
BENEFITS OF THE USE OF EHR TECHNOLOGY (5)
- Improve healthcare quality, safety, and efficiency and
reduce health disparities - Engage patients and families in their health care
- Improve care coordination
- Improve population and public health
- Ensure adequate privacy and security of personal health
information
Secure website through which patients can electronically
access their medical records
PATIENT PORTAL
Patient portal enables users to
o Complete forms online
o Schedule appointments
o Communicate with provider
o Request refills on prescriptions
o Review test results
o Pay bills
fully functional EHRs
provide
order entry capabilities beyond ordering
medications and decision support capabilities
FACTORS THAT INCREASE EHR ADOPTION
o Improve patient safety o Reduce medical errors o Reduce duplicate services o Improve organizational efficiency o Optimize reimbursement o Complete locally and regionally
Barriers to Adoption
- Financial Barriers
- Organizational or Behavioral Barriers
- Technical Barriers
T OR F
EHR may not be the same as those in the developed
countries
TRUE
a type of patient record is
maintained by the individual to track personal healthcare
information
Personal health record (PHR)
T OR F
PHR is not the same as [other] health records
TRUE
PHR is not the same as [other] health records because
it is not managed by a healthcare organization or
provider
T OR F
PHR constitutes a legal document of care but
contains all pertinent health care information contained
in an individual’s health record
FALSE
Does not constitute a legal document of care but
contains all pertinent health care information contained
in an individual’s health record
effective tool enabling patients to
be active members of their own health care teams
PHR
t or f
patient records may contain
some or all of the documentation listed
TRUE
a repository for a variety
of healthcare data and information which is captured by
many different individuals involved in the care of the patient
Patient record
Information found in the identification screen of a health or
medical record originates at
at the time of registration or
admission of our patient
INCLUDES
o Patient’s name, address, and telephone number
o Insurance carrier (most likely needed, personal
information has a great impact for insurance
companies)
o Policy number
o Diagnoses and disposition at discharge
Identification screen
TRUE OR FALSE
Problem list is used as clinical and administrative document
FALSE
Identification screen is used as clinical and administrative document
T OR FALSE
Identification Screen is not only used for patient management, but also reimbursement
or possible insurance claims
TRUE
• Includes diagnosis and health condition of patient
• Frequently contains a comprehensive problem list which
identifies significant illness and operations the patient has
experienced
Problem list
T OR F
Problem list is Generally maintained over time
By attending or primary care physician, or health care
providers involved in patient care
o Not specific to a single episode of care (naeedit or
nadagdagan over time)
TRUE
Who is responsible in documenting and maintaining information in medical records?
Nursing personnel
- Lists medicines prescribed and subsequently administered
* List medication allergies experienced by the patient
Medical records / Medical Administration record
Medical record is also known as the
Medical Administration Record
This component describes: o Any major illnesses and surgeries the patient had o Family history of disease o Patient health habits o Current medications
History
Documented by physician or other care provider at the
beginning of or immediately prior to an encounter or
treatment episode
History
This component of the report states:
o What the physician found after the hands-on patient
examination
Physical
o Documents that will provide the initial assessment of
the patient for the particular care episode
o Provide basis for diagnosis and subsequent treatment
o Provide a framework in which physicians and other
care providers can document significant findings
o Important and created initially during the first encounter
with the patient
History and Physical
T OR F
initial history and physical
observations is a one-time activity
TRUE
Results of reassessments are generally recorded here
progress notes
Should reflect patient’s response to treatment along with
observations and plans for continued treatment
progress notes
T OR F
The patient is responsible for the content of progress notes
FALSE
Each provider is responsible for the content of his/her notes
FORMAT OF PROGRESS NOTES
SOAP FORMAT o Subjective findings o Objective findings o Assessment o Plan
• Records opinions about the patient’s condition
• Made by another health care provider at the request of the
attending physician
Consultation note or report
• Directions, instructions, or prescriptions • Given to other members of the health care team regarding the patient’s: o Medications o Tests – laboratory, radiologic o Diets o Treatments o Rehabilitation, etc
Physician’s order
Interpret images produced by x-rays, mammograms,
ultrasounds, scans, and other medical imaging
machines
Radiologist
T OR F
Imaging and X-ray reports and images are typically not considered part of the legal
patient record per se
TRUE
Contain results coming from a clinical laboratory or
anatomic pathology laboratory
LABORATORY REPORTS
a legal document o Admission o Treatment o Surgery o Release of information o Or anything that will be performed or done to the patient NEEDS
Consent and authorization forms
- Describes any surgery performed
* Lists the names of surgeons and assistants
Operative Report
Responsible for the information found in operative report
Surgeon
- Describes tissue removed during any surgical procedure
* Diagnosis based on examination of the tissue
Pathology report
Responsible for the information found in pathology report
pathologist
Summarizes the hospital stay including: o Reason for admission o Significant findings from tests o Procedures performed o Therapies provided o Responses to treatments o Condition at discharge o Instructions for medications, activity, diet and follow-up care
Discharge summary
T OR F
Each acute care patient record contains a discharge
summary
TRUE
Responsible for information in discharge summary
Attending physician
