Lecture-EHR (not sure why i made this one either) Flashcards
List some Meaningful Use criteria (laundry list)
- demographics
- maintain active med, allergy, problem lists
- record and chart changes in Vitals, including BMI, growth charts for kids
- RECORD SMOKING STATUS
- drug/drug and drug/allergy interaction checks
- computerized physician order entry
- generate and transmit permissible Rx electronically
- implement 1 clinical decision support tool
- capability to exchange pt info between providers and acceptable entities electronically
- provide clinical summaries for each pt at each visit
- provide pts with electronic versions of their health data upon request
- report total of 6 ambulatory clinical quality measures to CMS or states
- protect pt health info through use of appropriate technical capabilities
- protect electronic health info w/appropriate technical capabilities
- ability to contact pt w/reminders for necessary health care using method per their preference
- ability to reference specific populations for tracking of recommended tests, labs, etc
- capability for pts access their records electronically, contact provider electronically
- ability to submit cancer cases to cancer registries
per CMS guidelines, attending doc must verify and redocument HPI and exam, can only “accept” students documentation of __
ROS or PMH, PSH, Soc hx, and Fam hx
MUSTS for medical students:
1-have OWN unique login and pw to chart on behalf of preceptor
2-contribute meaningful data to the EHR with inclusion of a student note or, at least, students review/update of past, family/social hx and ROS
3-enter data into appropriate fields in EHR
4-have all notes reviewed, edited, signed by supervising doc, with appropriate instructive feedback given
Ideally, student should also *:
1-have at a minimum 1 note per day routed to preceptor for feedback
2-review screening and prevention recommendations for given pt, bring to atn of supervising doc if needed
3-become familiar w/: selection of dx’s, CPT/ICD-10 codes and how these are linked to billing; order entry including linking dx to tests; E-Rx; pt-centered medical home metrics; meaningful use metrics; query functions that practices use for population mgmt, if available