Medical Records/Electronic Health Record Flashcards
What does electronic health records help do? (4)
- eliminates duplication of forms
- lost or misfiled paper records
- unreadable prescription orders
- inaccurate and illegible documents
What are the 4 types of older forms of record storage?
- filing shelves
- rolling shelves
- lateral files
- vertical files
What are the 5 basic steps for filing?
- conditioning
- releasing
- indexing and coding
- sorting
- sorting and filing
What is conditioning?
- grouping related papers together
- removing paper clips and staples
- fixing damaged records
What is releasing?
Marking the form to be filed; ready to be filed
What is indexing and coding?
determining where to place the file in the record
What is sorting?
Ording papers in a filing structure
- placing files in specific groups
What is sorting and filing?
securing documents permanently in the file
What are the 3 types of filing?
- alphabetic
- numeric
- subject
What is alphabetic filing?
Most widely used
- last name, first name, middle initial
What is numeric filing? (4)
- Combined with color coding
- used in larger facilities
- allows for unlimited expansion
- saves time
What is subject filing?
- used for general correspondence
- all correspondence placed under a specific subject and specific tab
Electronic medical record
digital charts to be used within a facility
Electronic health record
Includes EMR and other information to be used b/w facilities
Personal health record (PHR)
- access controlled solely by patient
- data entered by the patient
- files are owned by the individual
- can be stored on secure internet sites
How long must medical records be kept?
Records must be kept for 10 years
How are PHRs different from EHRs?
PHR are not legal documents under federal law regulation, data is not entered by healthcare professionals, and cannot be disclosed without the patient’s written permission
What are some advantages of EHR programs? (4)
- Fewer lost medical records
- Increased readability/legibility
- Chart availability outside of office hours
- Accessed from other locations
How to correct an EHR?
Use a new entry for corrections –> called an addendum
What is the proper way to protect a patient’s information on a computer?
- Log off station when not using the computer
What are the 3 basic components of meaningful use?
- use of a certified EHR in a meaningful manner
- Electronic exchange of health information to improve the quality of healthcare
- Use of certified EHR technology to submit clinical quality and other measures
What is the release of information (ROI) form?
- Allows practice to share patient information
- Allows patient to authorize who can access their medical information
- also known as the “HIPAA” form
What is the consent to treat form?
Gives the physician permission to treat a child
Who can authorize forms?
- patient
- minor’s parent/legal guardian
- power of attorney
