MODULE 2 UNIT 4 Flashcards
essential compilation of facts about a patient’s life and health
MEDICAL RECORD
includes documented data on past and present illnesses and treatment written by health care professionals caring for the patien
medical record
must contain sufficient data to identify the patient, support the diagnosis or reason for attendance at the health care facility, justify the treatment and accurately document the results of that treatment
medical record
record the facts about a patient’s health with an emphasis on events affecting the patient during the current admission or attendance at the health care facility, and for the continuing care of the patient when they require health care in the future.
primary purpose of medical record
patient’s medical record should provide accurate information on:
1) who the patient is and who provided health care;
2) what, when, why and how services were provided; and
3) the outcome of care and treatment.
medical records has four major sections
administrative
legal data
financial data
clinical data
includes demographic and socioeconomic data such as the name of the patient (identification), sex, date of birth, place of birth, patient’s permanent address, and medical record number;
administrative
including a signed consent for treatment by appointed doctors and authorization for the release of information;
legal data
relating to the payment of fees for medical services and hospital accommodation
financial data
data on the patient, whether admitted to the hospital or treated as an outpatient or an emergency patient
clinical data
main uses of the medical record are:
1) to document the course of the patient’s illness and treatment;
2) to communicate between attending doctors and other health care professionals providing care to the patient;
3) for the continuing care of the patient;
4) for research of specific diseases and treatment; and
5) the collection of health statistics.
first step in every admission procedure
assignment of a medical record number or verification of an existing medical record number
This number is then used during the current admission and in the future to identify a patient and his or her medical record.
medical record number
permanent identification number assigned in a straight numerical sequence by the admission staff and is recorded on all medical record forms relating to that particular patient.
medical record number
how we give a number to medical records
medical record numbering systems
how we file the record after a number has been given
filling system
physical medical record will eventually consist of the following:
1) medical record forms;
2) a clip or fastener to hold the papers together;
3) dividers between each admission and outpatient notes; and
4) a medical record folder.
covers identification, final diagnoses, disease and operation codes, and the attending doctors signature;
front sheet/ identification/ summary sheet
often on the back of the front sheet and must be signed by the patient at the time of admission.
consent for treatment
first half of the concent for treatment form
general consent for treatment
bottom half of teh consent for treatment form
consent to release information to authorized persons;
referral letter, requests for information
correspondence and legal documents received about the patient,
recording the patient’s daily treatment and reaction to that treatment written by the attending doctor and other health care professionals;
cilinal progress notes
recording regular nursing care including temperature, pulse and respiration charts, blood pressure charts, etc.;
nurse’s progress report
report if an operation or operations are performed;
operation report
listing daily medications ordered and given with signatures of the doctor prescribing the treatment and the nurse administering it
orders for treatmnet and medication forms
forms for observation of head injuries etc.
special nursing forms
to provide quality patient care to all patients, whether an inpatient, outpatient, or emergency patient
primary function of a hospital, clinic and helath care facility
legally responsible for the quality of care given to patients.
hospital administration
delegated to doctors, nurses, and other health care professionals.
responsibility for direct patient care and documentation in patient’s medicla record
person in charge of the Medical Record Department has delegated responsibility for the functions of that department and overall management of the medical record service. T
medical record officer
he or she is responsible for the management of patient health care data on a continuing daily basis.
Medical record officer
seeing that the medical record is available at all times when needed for the continuing care of the patient.
medical record officer
1) seeing that all forms related to the care of a particular patient are in that patient’s medical record;
MRO
seeing that staff are trained and understand the value of the medical record and the importance of its availability at all times;
MRO
3) making sure that the doctor has completed the medical record;
MRO
making sure that diseases and operations are coded accurately and within a specified period
MRO
seeing that all information produced for statistics is accurate and readily available when required by the administration, Ministry of Health, or other government agencies.
MRO
an emerging field in the intersection of medical informatics, public health, and business, referring to health services and information delivered or enhanced through the Internet and related technologies.
eHealth
characterizes not only a technical development, but also a state-of-mind, a way of thinking, an attitude, and a commitment for networked, global thinking, to improve health care locally, regionally, and worldwide by using information and communication technology
eHealth
one of the promises of e-health is to increase ——— in health care, thereby decreasing costs
efficiency
One possible way of reducing costs
avoiding duplicative or unnecessary diagnostic or therapeutic interventions,
allowing comparisons between different providers, involving consumers as additional power for quality assurance, and directing patient streams to the best quality providers.
enhancing quality of care
effectiveness and efficiency should not be assumed but proven by rigorous scientific evaluation. Much work still has to be done in this area.
evidence-based
between the patient and health professional, towards a true partnership, where decisions are made in a shared manner.
encouragement of a new relationship
——– of physicians through online sources (continuing medical education) and consumers (health education, tailored preventive information for consumers)
education
——- information exchange and communication in a standardized way between health care establishments.
enabling
the scope of health care beyond its conventional boundaries
extending
This is meant in both a geographical sense as well as in a conceptual sense. eHealth enables consumers to obtain health services online from global providers easily.
extending
These services can range from simple advice to more complex interventions or products such as pharmaceuticals.
extending
eHealth involves new forms of patient-physician interaction and poses new challenges and threats to ethical issues such as online professional practice, informed consent, privacy, and equity issues.
ethics
there is a considerable threat that e-health may deepen the gap between the “haves” and “have-nots.”
equity
People who do not have the money, skills, and access to computers and networks cannot use computers effectively.
equity
computerized medical record or digital patient record that can include demographics, test results, medical history and examination, images, etc. and can be accessed via computer over a network
EHR or EMR
physical and psychological treatment at a dstance
telemedicine and telecare applications
digital versions of the paper charts in clinician offices, clinics, and hospitals
EMR
contain providers mostly use notes and information collected by and for the clinicians in that office, clinic, or hospital and diagnosis and treatment.
EMR
more valuable than paper records because they enable providers to track data over time, identify patients for preventive visits and screenings, monitor patients, and improve health care quality.
EMR
are built to go beyond standard clinical data collected in a provider’s office and are inclusive of a broader view of a patient’s care.
EHR
contain information from all the clinicians involved in a patient’s care and all, authorized clinicians involved in a patient’s care can access the information to provide care to that patient.
EHR
share information with other health care providers, such as laboratories and specialists.
follow patients – to the specialist, the hospital, the nursing home, or even across the country.
EHR
contain the same types of information as EHRs—diagnoses, medications, immunizations, family medical histories, and provider contact information—but are designed to be set up, accessed, and managed by patients
PHR
maintain and manage their health information in a private, secure, and confidential environment.
can include information from a variety of sources, including clinicians, home monitoring devices, and patients themselves.
PHR
to support the achievement of health objectives has the potential to transform the face of health service delivery across the globe
mobile helath or mHealth
Smart devices and wearable technologies
mHelath
medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other wireless device
mHelath
involves the use and capitalization on a mobile phone’s core utility of voice and short messaging service (SMS) as well as more complex functionalities and applications including general packet radio service (GPRS), third and fourth generation mobile telecommunications (3G and 4G systems), global positioning system (GPS), and Bluetooth technology
mHealth
used to monitor a variety of conditions, including heart disease, diabetes, autism, insomnia, and asthma
mhealth
has already helped improve hypertension detection and control in 414,167 people
American Medical Group Foundation titled “measure up/pressure down”
could allow for earlier interventions and significantly decrease admissions to hospital, along with visits to GPs and healthcare practitioners generally.
advantages of mhelath
include patient records, e-prescribing, clinical administration systems, e-booking, and digital imaging, and archiving systems.
Electronic Health Records (EHR) and Electronic Medical Records (EMR)
transmit medical information for diagnostic purposes resulting in lower costs increased patient access and optimized the use of digital health assets.
telemedicine and telehealth system
include thousands of health-oriented websites and hundreds of thousands of mobile health apps that are becoming increasingly popular.
consumer informtaics application
radiology, nursing healthIT systems, computerassisted diagnostics, medical imaging, and surgery training and planning systems that help physicians provide more accurate diagnoses and treatments.
Clinical helath IT systems
allow health services to be deployed in remote and rural areas.
Integrated regional, national, and international networks
such as health portals – that are widely used to disseminate health information to promote healthy behaviors in patients and consumers.
online helath IT system
used by researchers for public health data collection and analysis – such as biostatistical programs for infectious diseases, drug development, and outcomes analysis.
specialized ehelath system
such as pharmaceutical supply chain management, scheduling systems, billing systems, hospital administration and management systems, and other clinical decision support processes.
eHealth tools and technologies for health IT support systems
technologies improve transparency and accountability in care processes and facilitate projection of care services across boundaries.
eHelath nuviuneHealth
improve access to digital health technologies by reducing physical barriers such as geographic location or disability.
eHelath technology
Factors influencing the eHealth market include:
Increasing participation of consumers in digital health outside of hospital settings
• Increasing awareness and acceptance by healthcare professionals
• Evidence of efficacy of eHealth technologies
• Decreasing costs of the deployment in some technologies such as software-as-aservice (SaaS), cloud computing and hosted services
• Favorable regulatory climates and improved support for interoperability
• The pressure to decrease healthcare costs
• The rise in aging population and incidences of chronic diseases
Factors restraining the growth of the eHealth market include:
• Continued resistance to change from healthcare professionals
• Inconclusive proof of the efficacy of some eHealth solutions • Complexity of systems
• Lack of supporting infrastructure
• High costs of health IT tools and technologies
• High maintenance and service costs
• Interoperability issues
• Regulatory concerns regarding privacy and security
• Shortage of trained professionals • Poor standard healthcare protocols
• Low budget allocations in hospitals for eHealth solutions
• Poor legacy systems
