Module4,

Question 1

Who is initiating computerized medical record keeping?

Answer 1

Provincial

Federal Governments

Question 2

What is the ULTIMATE end result?

Answer 2

ONE RECORD-ONE PATIENT

Question 3

What are the advantages of electronic medical record keeping?

Answer 3

SPACE
ACCESSIBILITY
EASIER BILLING

Question 4

What are the DISadvantages of medical record keeping?

Answer 4

Cost of transferring
Time consumption
Glitches

Question 5

How is (EMR) Electronic Medical Record used in the examining room?

Answer 5

-up-to-date lab results,
consultations and test
-DR's health info documents
-Patient can sign paperless
documents.

Question 6

EMR components that physicians would access during a physical exam

Answer 6

flow sheet
past medical history
encounter record
medication profile
problem list
allergy alert
laboratory/diagnostic test

Question 7

Electronic safeguards EMR systems have in ALBERTA

Answer 7

Personal Authorization
Unique Identifier per employee
Different ACCESS LEVELS
PASSWORD
AUDIT TRAIL 
ELECTRIC Signature authentication

Question 8

What are the two ways that clinical records are classified when entering data into EMR?

Answer 8

TEMPLATES such as SOAP
Information entered into defined fields.
Fully structured ( fill in blanks) 
Open text ( fill in blanks)

Question 9

What is a tickler file?

Answer 9

Reminder

Question 10

What is archiving?

Answer 10

a file from ACTIVE use and storing it in a secondary location or
MEDIUM

Question 11

Define ACTIVE, INACTIVE, CLOSED FILES

Answer 11

Active: still in use
Inactive: patient not seen for awhile for some time.
Closed: Patient left practice or deceased.

Question 12

Inactive and Closed files stored for and how long?

Answer 12

Alberta: 10 years from date of separation from hospital.

PATIENT is a minor- a periods of 10 years or 2 years past the date of majority, whichever is longer.

Question 13

How are archived paper records filed?

Answer 13

• be retrieved quickly -accessibility
• organized by year or range of years.
• same filing systems as active charts.

Question 14

How are electronic charts archived? Do electronic charts need to be archived?

Answer 14

YES

-Relocated to another MEDIUM.

Question 15

Name four ARCHIVING options

Answer 15

• MICROFILM
• MICROFICHE
• CD Rom - electronically generated information
• MAGNETIC TAPE- temporary storage medium for computer generated information. ( scanned, often used for backing up computer information.)

Question 16

What is a centralized system of storage?

Answer 16

-private practice
hospital (health information dept)
-all records- in & outpatient kept in one file, one location.
-purged (centralized records)

Question 17

What is a decentralized system of storage?

Answer 17

• parts of patient records reside outside central area.
• hospital have clinics that store charts separately ( cast clinics/diabetes)
• records separate due to sensitive nature (abortion clinic/AIDS)

Question 18

Why would files be somewhere other than the centralized or de-centralized filing system?

Answer 18

• pulled for reference
• reviewed
• awaiting lab results or letter to add to chart.
• dictation
• billing