Electronic Health Records Flashcards
1
Q
Def: Electronic Medical Records (EMR)
A
Digitized version of the paper charts in the clinician’s office but the information in EMRs doesn’t travel easily out of the practice
2
Q
Def: Electronic Health Records (EHR)
A
EMR records built to share inforamtion w/ other health care providers
3
Q
Who was Dr. Lawrence Weed
A
Developed the POMR (Patient Oriented Medical Record) which became the SOAP note
4
Q
What are the 3 stages of meaningful use
A
1 = data capture and sharing 2 = advanced clinical processes 3 = improved outcomes
5
Q
What part of the SOAP note must be verified and redocumented by the attending physician
A
HPI and PE
6
Q
What part of the SOAP note can the attending physician “accept” from the student
A
ROS PMH PSH SH FH
