Medical Records/Electronic Health Record Flashcards

You may prefer our related Brainscape-certified flashcards:
1
Q

What does electronic health records help do? (4)

A
  • eliminates duplication of forms
  • lost or misfiled paper records
  • unreadable prescription orders
  • inaccurate and illegible documents
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2
Q

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

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

What are the 5 basic steps for filing?

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

What is conditioning?

A
  • grouping related papers together
  • removing paper clips and staples
  • fixing damaged records
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5
Q

What is releasing?

A

Marking the form to be filed; ready to be filed

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6
Q

What is indexing and coding?

A

determining where to place the file in the record

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7
Q

What is sorting?

A

Ording papers in a filing structure

  • placing files in specific groups
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8
Q

What is sorting and filing?

A

securing documents permanently in the file

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9
Q

What are the 3 types of filing?

A
  • alphabetic
  • numeric
  • subject
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10
Q

What is alphabetic filing?

A

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

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11
Q

What is numeric filing? (4)

A
  • Combined with color coding
  • used in larger facilities
  • allows for unlimited expansion
  • saves time
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12
Q

What is subject filing?

A
  • used for general correspondence
  • all correspondence placed under a specific subject and specific tab
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13
Q

Electronic medical record

A

digital charts to be used within a facility

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14
Q

Electronic health record

A

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

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15
Q

Personal health record (PHR)

A
  • access controlled solely by patient
  • data entered by the patient
  • files are owned by the individual
  • can be stored on secure internet sites
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16
Q

How long must medical records be kept?

A

Records must be kept for 10 years

17
Q

How are PHRs different from EHRs?

A

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

18
Q

What are some advantages of EHR programs? (4)

A
  • Fewer lost medical records
  • Increased readability/legibility
  • Chart availability outside of office hours
  • Accessed from other locations
19
Q

How to correct an EHR?

A

Use a new entry for corrections –> called an addendum

20
Q

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

A
  • Log off station when not using the computer
21
Q

What are the 3 basic components of meaningful use?

A
  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
22
Q

What is the release of information (ROI) form?

A
  • Allows practice to share patient information
  • Allows patient to authorize who can access their medical information
  • also known as the “HIPAA” form
23
Q

What is the consent to treat form?

A

Gives the physician permission to treat a child

24
Q

Who can authorize forms?

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