his unit 6 3rd shift Flashcards
Collection of computer-stored images of traditional health record documents
AHR Automated Health Records
How are AHRs stored/ collected?
Scanned into a computer
Stored on optical disks
Contains all personal health information belonging to an individual
EHR
Collection of health information for one patient linked by a patient identifier
CPR Computer-based Patient Record
What can be included in a CPR?
Medication orders
Integrated data on a patient’s registration
Admission and financial details
Recording information from nurses, laboratory, radiology, and
pharmacy
T or F: EHR extends beyond acute inpatient situations
T
EHR is entered and accessed electronically by healthcare
providers over ______
the person’s lifetime
Developed within a medical practice or health center
EMR
Describe automated systems based on document imaging or systems
EMR
What does a EMR include?
Include patient identification details, medications and prescription generation, laboratory results, and healthcare information recorded by the doctor
The EHR should reflect the ______ of an individual across his or her
lifetime including data from multiple providers from a variety of healthcare settings
entire health history
Share information with other health care providers and organizations
EHR
EMR enables clinicians to?
Track data over time
Easily identify who are due for screenings or checkups
Check their patients
Monitor and improve overall quality of care within the practice
Focus on the total health of the patient
EHR
Going beyond standard clinical data collected
EHR
Contains medical and treatment history of patients in one practice or organization
EMR
Can be gathered, managed, consulted by clinicians and staff in one healthcare organization
EMR
Conforms to interoperability standards that can be drawn from multiple sources while being shared, managed, and controlled by the individual
PHR
Conforms to nationally recognized interoperability standards
Can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization
EHR
What is the major issue that should be address before moving forward?
unique patient identification
What is the backbone of an
effective and efficient health record system, whether manual or electronic?
Accurate patient identification
Other possible issues of EHR?
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
What safeguards need to be addressed?
Efficient back-up system available
Contingency plans for disaster recovery
Securing workstations and password requirement
Access control to authorized persons only
Audit controls
Staff may be available, but their skills may not be adequate
There is a need for a well-trained workforce
Manpower issues– lack of staff with adequate skills
Retention schedules
Concerned with how information is to be retrieved
Concerns about privacy, confidentiality and the quality and accuracy of electronically generated information
Need to compare the current system costs plus perceived costs for the new EHR system
High cost of computers and computer systems
Need to adopt a standard, comprehensive vocabulary and develop a data dictionary
Clinical data entry issues and lack of standard terminology
Some prefer to write by hand
Some are still not proficient in using computers
Resistance to computer technology and lack of computer literacy
The change to entering patients’ health record data via a computer or other electronic device may be difficult.
Requires intensive training of healthcare practitioners
Strong resistance to change by many healthcare providers
Information should always be readily available can be accessed more efficiently
Concern by providers as to whether information will be available on request
What are qualities of quality data?
Accuracy and validity of the original source data
Reliability
Completeness
Legibility
Currency and timeliness
Accessibility
Limited coding training programs
Selected people who do not have a medical background
Lack of staff with adequate knowledge of disease classification systems
Thorough understanding of clinical data Their specifications and input
Willingness to collaborate and share data
Involvement of clinicians and hospital administrators
Electrical wiring and supply of electricity
Amount and quality of space needed for computers and other equipment
Environmental Issues
Core functions of an EHR system?
Health information and data
Results management
Order entry and support
Decision support
Other functions of an EHR system?
Electronic communication and connectivity
Patient support
Administrative processes
Reporting and population health management
Benefits of using EHR technology?
- Improve health care 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
What is a patient portal?
Secure website through which patients can electronically access their medical records
Patient portals enables users to?
- Complete forms online
̶ Schedule appointments
̶ Communicate with providers
̶ Request refills on prescriptions
̶ Review test results
̶ Pay bills
Factors that increase EHR adoption?
- Improve patient safety
- Reduce medical errors
- Reduce duplicate services
- Improve organizational efficiency
- Optimize reimbursement
- Complete locally and regionally
Barriers to Adoption?
Financial
Organizational / Behavioral
Technical
Use and acceptable of changes in workflow
Organizational / Behavioral
Lack of capital or resources needed to develop, acquire, implement, and support a healthcare information system
Financial
Work and technology needed to build system interfaces
Technical
According to AHIMA (2016) what is a personal health record?
tool to collect, track, and share past and current information about your health or the health of someone in your care
effective tool enabling patients to be active members of their own health care teams
T or F: PHR is managed by your healthcare provider
F is it not
T or F: PHR does not constitute a legal document of care
T
Should PHR contain all pertinent health care information?
YES
Patient Record Content has?
Identification Screen
Problem List
Medical Record
History and Physical
Progress Notes
Consultation Note or Report
Physician’s Orders
Imaging and X-ray Reports
Laboratory Reports
Consent and Authorization Forms
Operative Report
Pathology Report
Discharge Summary
Contain results of tests conducted on body fluids, cells, and tissues
Laboratory Reports
Who in the lab documents any findings and treatment plans based on lab
results?
Physicians
Who documents lab results into the patient record?
Lab personnel
T or F: Lab Reports must be present during treatment
T
Documented in a timely manner
Imaging and X-ray Reports
Responsibilities of the radiologist?
Interpret images
Document interpretations or findings
Identifies significant illness and operations
Problem List
Used as clinical and administrative document
Identification Screen
How is the problem list maintained over time?
By attending or primary care physician, or health care providers involved
Made by physicians, nurses, therapists, social workers, and other staff members
Reflect patient’s response to treatment; observations and plans for continued treatment
Progress Notes
What is the format for Progress Notes?
SOAP
Subjective findings
Objective findings
Assessment
Plan
Practitioner who provides treatment must obtain ______
informed consent
What needs the consent as alegal document?
STAR
Surgery
Treatment
Admission
Release of information
Describes any surgery performed
Lists the names of surgeons and assistants
Operative Report
In a Operative Report, who documents the information?
Surgeons
Discharge Summary summarizes?
- Reason for admission
̶ Significant findings from tests
̶ Procedures performed
̶ Therapies provided
̶ Responses to treatments
̶ Condition at discharge
̶ Instructions for medications, activity, diet and follow-up care
Discharge summary documented by?
Attending physician
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
Physician’s Orders
Lists medicines prescribed and administered, medication allergies
Medical Record AKA Medication Administration Record (MAR)
Who are responsible for documenting and maintaining information?
Nursing personnel
Information originates at the time of registration or admission?
Name, address and telephone number
Insurance carrier
Policy number
Diagnoses and disposition at discharge
Identifies significant illness and operations
Problem List
History component describes?
- Any major illnesses and surgeries the patient had
̶ Family history of disease
̶ Patient health habits
̶ Current medications
What the physician found after the hands-on patient examination
Physical component
Both history and physical components?
Document the initial patient assessment and provide basis for diagnosis and treatment
History is provided by who and documented by who?
̶ Information is provided by the patient
̶ Documented by physician or other care provider
May come from physicians and others inside or outside the organization
Consultation Note or Report
Physician’s orders are given to other members of the health care team
regarding the patient’s?
- Medications
̶ Tests
̶ Diets
̶ Treatments, and others
