healthcare documentation quiz Flashcards
CHI
computerized health information
EMR
electronic medical record
EHR
electronic health record
EPR
electronic pt record
CPR
computerized pt record
PHR
personal health records
PHI
personal health information
PMR
pt medical record
PMRI
pt medical information
e-sign
digital signature
EP
eligible professional
EOE
electronic order entry
CPG
clinical practice guidelines
CPM
clinical performance measures
CI
clinical indications
CPOE
computerized physician order entry
POC
point of care
formulary
standard pharmacy of facility
EBM
evidenced based practice
SNOMED
global language of healthcare
WOW
workstation on wheels
COW
computer on wheels
EHT
electronic health technology
role of EHT
- improve the quality of health care
- prevent medical errors
- reduce health care costs
- increase administrative efficiencies
- decrease paperwork
- expand access to affordable healthcare
- maintain client privacy laws
EH
eligible hospitals
CAHs
critical access hospitals
centers of medicare & medicaid services (CMS)
- incentive programs provide incentive payments to EP, EH, and CAHs
- as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology
“meaningful use”
-using certified EHR technology in ways that can positively impact pt care
examples of meaningful use
- CPOE for medication orders
- record VS
- medication reconciliation
- advance directives
- recoding smoking status
- active medication list
healthcare outcomes
- improve quality, safety, efficiency, and reduce health disparities
- engage pts and families in their healthcare
- improve care coordination
- ensure adequate privacy and security protections for PHI
- improve individual and community health
EHR/EMR include this important info
- immunizations
- allergies
- demographics
- advanced directives
- appts
- insurance/fin info
- MD orders
- H&P
- nurse charting
- current meds
- lab/dx test restults
- adjunct care
- consults
levels of automation
- administrative (pt info, address, contacts, insurance, billing, etc)
- clinical date repository (basic clinical documentation)
- barcode medication
- ancillary orders/reports: lab, dx, radiology
- healthcare personnel communications
- pt portals
- MD access from mobile devices
- able to predict and address epidemic issues for any area using historical data and other factors
clinical vocabulaires
- use of a standardized vocab
- ex: leukopenia vs low white blood count
- without this, an automated system cannot recognize terms as being equivalent when queried
