Medical Records & Health Info Technology

Question 1

medical records

Answer 1

collection of data recorded when a patient seeks medical treatment

Question 2

Medical record purposes

Answer 2

1. required by licensing authorities and provide a format for tracking, documenting, maintaining a patient’s communication data, inside and outside a health care facility
2. documentation of a patients continuing health care from birth to death
3. provide a foundation for managing a patient’s health care
4. serve as legal documents in lawsuits
5. provide clinical data for education, research, statistical tracking, and assessing the quality of health care

Question 3

electrical medical record (EMR)

Answer 3

digital version of paper charts in clinicians office

Question 4

EMR’s allow clinicians to?

Answer 4

• track data over time

-easily identify which patients are due for preventive screenings or checkups

-check how their patients are doing on certain parameters (blood pressure/vaccinations)

-monitor and improve overall quality of care within practice

Question 5

electronic health record (EHR)

Answer 5

built to share info with other health care providers , such as labs, specialists, hospitals

Question 6

Five Cs

Answer 6

concise, complete(objective), clear, correct, chronologically ordered

Question 6

addendum

Answer 6

new documentation used to add info to original entry

Question 6

correction

Answer 6

change in the info that is meant to clarify inaccuracies found after the document is complete

Question 7

amendment

Answer 7

used to clarify or correct info in the electronic health record

Question 8

doctrine of professional discretion

Answer 8

physician can exercise judgement as to whether to show patients who are being treated for mental or emotional conditions their records.

disclosure depends on whether patients would be harmed by viewing the records

Question 9

Confidentiality of Alcohol and Drug abuse patient records

Answer 9

federal statute that protects patients with histories of substance abuse regarding the release of info about treatment

Question 10

health info technology (HIT)

Answer 10

electronic systems health care professionals - increasingly, patients - used to store, share and analyze health info

Question 11

meaningful use

Answer 11

health care providers use an electronic health record according to guidelines set by fed gov

Question 12

patient portals

Answer 12

secure online site that gives patients 24

Question 13

social media

Answer 13

forms of electronic communication through which users create online communities to share info, ideas, personal messages, other content in online environment

Question 14

telemedicine

Answer 14

remote delivery of health care services and clinical info using telecommunications technology