Midterm #1 Flashcards
What are the most used (HIS) in Canada?
Meditech, Epic and Cerner
What is (HIS) and what is the purpose of it?
A hospital information system, it is designed to manage numerous aspects of health data in a health care facility.
What are (HIS) purposes?
- Order entry
- Clinical documentation
- Communication
- Billing
- Medication Log
- Generating Reports
- Payroll
What is a health record?
Any documentation relating to a patient.
What is a record?
A record refers to a single document, such as a doctor’s note or and assessment or a lab report.
What is a chart?
A chart is the collection or file folder of such documents.
What is an EMR?
Electronic medical record
It is a patient record maintained by a physician overtime - essentially a patient chart, but in electronic form.
What is an EHR?
Electronic Health Record
It is a compilation of a patient’s health data from multiple sources.
What are the components of an electronic record?
- Patient profile
- Progress notes
- Physical assessments
- Laboratory results report
- Consent forms
What is the Life Cycle of a Record?
Creation - of a patient’s record
Maintenance - via a filing or indexing system
Provision - of policies and level of access to patient records
Disposition - and archiving of records
What is the cycle of a health record?
- Retrieval of information
- Storage
- Management of information
What does a complete EMR include?
- Basic demographics
- Medical history
- Social and family history
- Functional inquiry
- History of present illness
- Diagnosis
- Treatments and medications
What does local solution mean?
Where the records are stored on a local hard drive. The back-up and security of the health information is the clinics responsibility.
What does central solution mean?
Where the information is hosted remotely by an application service provider. The provider retrieves/stores off-site. The vendor is responsible for the back-up security.
All EMR systems must offer what?
- An audit trail
- The ability to allow providers to sign off on entries using electronic signatures
- The means to regularly save and back up data
- Effective protocols for information recovery
When are charts considered inactive?
When a provider has not seen a patient for a certain period of time but is not sure whether the patient has left the practice.
When are charts considered closed?
When patients leave the practice for any reason (including death).
What is the Privacy Act?
The privacy act concerns departments and agencies within the federal government in terms of outlining obligations, rules and policies related to collection, disclosure and use of personal information.
What does (PIPEDA) stand for?
The Personal Information Protection and Electronic Documents Act
What is the (PIPEDA)?
PIPEDA outlines how organizations within the private sector (including all
health-care agencies, drug companies, offices and clinics) can collect, use,
or disclose personal information.
What are the 10 principles of PIPEDA?
- Accounting
- Identifying purposes
- Consent
- Limits to information
- Limits to use of information
- Accuracy
- Safeguards
- Openness
- Individual access
- Challenging compliance
Health records have a dual ownership. Who are the owners of the health record?
What are the different types of Admission?
- Pre booked or Elective admission
- Obstetrical
What are Pre-booked or Elective admissions?
- They occur when the admission is scheduled ahead of time.
- An elective admission can also be for extensive and/or invasive diagnostic tests.
- Most of the paperwork is completed ahead of time.
