Medical Records/Electronic Health Record

Question 1

What does electronic health records help do? (4)

Answer 1

• eliminates duplication of forms
• lost or misfiled paper records
• unreadable prescription orders
• inaccurate and illegible documents

Question 2

What are the 4 types of older forms of record storage?

Answer 2

1. filing shelves
2. rolling shelves
3. lateral files
4. vertical files

Question 3

What are the 5 basic steps for filing?

Answer 3

1. conditioning
2. releasing
3. indexing and coding
4. sorting
5. sorting and filing

Question 4

What is conditioning?

Answer 4

• grouping related papers together
• removing paper clips and staples
• fixing damaged records

Question 5

What is releasing?

Answer 5

Marking the form to be filed; ready to be filed

Question 6

What is indexing and coding?

Answer 6

determining where to place the file in the record

Question 7

What is sorting?

Answer 7

Ording papers in a filing structure

• placing files in specific groups

Question 8

What is sorting and filing?

Answer 8

securing documents permanently in the file

Question 9

What are the 3 types of filing?

Answer 9

• alphabetic
• numeric
• subject

Question 10

What is alphabetic filing?

Answer 10

Most widely used
- last name, first name, middle initial

Question 11

What is numeric filing?

Answer 11

• Combined with color coding
• used in larger facilities
• allows for unlimited expansion
• saves time

Question 12

What is subject filing?

Answer 12

• used for general correspondence
• all correspondence placed under a specific subject and specific tab

Question 13

Electronic medical record

Answer 13

digital charts to be used within a facility

Question 14

Electronic health record

Answer 14

Includes EMR and other information to be used b/w facilities

Question 15

Personal health record (PHR)

Answer 15

• access controlled solely by patient
• data entered by the patient
• files are owned by the individual
• can be stored on secure internet sites

Question 16

How long must medical records be kept?

Answer 16

Records must be kept for 10 years

Question 17

How are PHRs different from EHRs?

Answer 17

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

Question 18

What are some advantages of EHR programs? (4)

Answer 18

• Fewer lost medical records
• Increased readability/legibility
• Chart availability outside of office hours
• Accessed from other locations

Question 19

How to correct an EHR?

Answer 19

Use a new entry for corrections –> called an addendum

Question 20

What is the proper way to protect a patient’s information on a computer?

Answer 20

• Log off station when not using the computer

Question 21

What are the 3 basic components of meaningful use?

Answer 21

1. use of a certified EHR in a meaningful manner
2. Electronic exchange of health information to improve the quality of healthcare
3. Use of certified EHR technology to submit clinical quality and other measures

Question 22

What is the release of information (ROI) form?

Answer 22

• Allows practice to share patient information
• Allows patient to authorize who can access their medical information
• also known as the “HIPAA” form

Question 23

What is the consent to treat form?

Answer 23

Gives the physician permission to treat a child

Question 24

Who can authorize forms?

Answer 24

• patient
• minor’s parent/legal guardian
• power of attorney