MT 637 UNIT 6 Flashcards
Why should we encourage the healthcare practitioners to move to an electronic system?
We should focus on encouraging them to:
1. Improve the accuracy and quality of data recorded in a health record
2. Enhance healthcare practitioners’ access to a patient’s healthcare information
3. Improve the quality of care
4. Improve the efficiency of the health record service
5. Contain healthcare costs
“An electronic health record is not a simple replacement of the paper record.”
A paperless environment will come.
“Current problems identified in healthcare documentation, as well as privacy and confidentiality issues must be addressed, and quality control measures introduced before a successful change can be implemented.”
A paperless environment will come.
Collection of computer-stored images of traditional health record documents
- Scanned into a computer
- Stored on optical disks
Automated Health Records (AHR)
What year focused on storing on optical disks; which addressed access, space, control problems
1990
What year focused on scanning documents alone
1990
Describe automated systems based on document imaging or systems
Electronic Medical Record (EMR)
Developed within a medical practice or health center
Electronic Medical Record (EMR)
EMR Includes:
○ patient identification details,
○ medications and prescription generation,
○ laboratory results, and
○ healthcare information recorded by the doctor
Collection of health information for one patient linked by a patient identifier
○ Medical alerts
○ Medication orders
○ Integrated data on a patient’s registration
○ Admission and financial details
○ Recording information from nurses, laboratory, radiology, and pharmacy
Computer-based Patient Record (CPR)
What year was CPR introduced?
1990s
Contains all personal health information belonging to an individual
Electronic Health Record (EHR)
Entered and accessed electronically by healthcare providers over the person’s lifetime
Electronic Health Record (EHR)
Extends beyond acute inpatient situations
Electronic Health Record (EHR)
EHR is also called
longitudinal health record
Includes dimension of time
Allows inclusion of information across providers which will evolve into lifetime record
EHR
TRUE/FALSE: The EHR should reflect the entire health history of an individual across his or her lifetime including data from multiple providers from a variety of healthcare settings.
True
Digital version of paper charts
Electronic Medical Record (EMR)
Contains medical and treatment history of patients in one practice or organization
Electronic Medical Record (EMR)
EMR enables clinicians to:
○ Track data over time
○ Easily identify who are due for screenings or checkups
○ Check their patients
○ Monitor and improve overall quality of care within the practice
Focus on the total health of the patient
○ Going beyond standard clinical data collected
○ Share information with other health care providers and organizations
○ Decision-support capabilities
Electronic Health Record (EHR)
TRUE/FALSE: EHR is present in the PH.
False
An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff in one healthcare organization
Electronic Medical Record
An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization
Electronic Health Record
An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual
Personal Health Record
What are the major issues?
Unique patient identification is a major issue that should be addressed before moving forward to automation - Control Problems
Accurate patient identification is the backbone of an effective and efficient health record system, whether manual or electronic - Typographical Errors
Other possible issues?
- Clinical Data Entry Issues & Lack of Standard Terminology
- Resistance to Computer Technology and Lack of Computer Literacy
- Strong Resistance to Change by many Healthcare Providers
- High Cost of Computers & Computer Systems & Funding Limitations
- Concern by Providers as to Whether Information will be Available on Request
- Concerns about privacy, confidentiality, and the quality & accuracy of electronically generated information
- Quality of electronic healthcare information & accuracy of data entries
- Lack of staff with adequate knowledge of disease classification systems
- Manpower issues
- Environmental issues
- Involvement of Clinicians & Hospital Administrators
What are the safeguards which may need to be addressed?
● Efficient back-up system available
● Contingency plans for disaster recovery
● Securing workstations and password requirement
● Access control to authorized persons only
● Audit controls
Simple Electronic Record System
➢ Patient ID Registration ATS
➢ Lab/haem/Path/Bio-Chem/Etc. Radiology
➢ Scanned documents / previous medical records
➢ Disease classification and indexing
➢ Clinical data treatment orders/results; OPD visits
Functions of an EHR System as Defined by the IOM
Core Functions or Other Functions?
Health information and data: includes medical and nursing diagnoses, a medication list, allergies, demographics, clinical narratives, and laboratory test results
Core
Functions of an EHR System as Defined by the IOM
Core Functions or Other Functions?
Results management: manages all types of results (for example, laboratory test results, radiology procedure results) electronically
Core
Functions of an EHR System as Defined by the IOM
Core Functions or Other Functions?
Order entry and support: incorporates use of computerized provider entry, particularly in ordering medications
Core
Functions of an EHR System as Defined by the IOM
Core Functions or Other Functions?
Decision support:
employes computerized clinical decision-support capabilities such as reminders, alerts, and computer-assisted diagnosing
Core
Functions of an EHR System as Defined by the IOM
Core Functions or Other Functions?
Electronic communication and connectivity: enables those involved in patient care to communicate effectively with each other and with the patient; technologies to facilitate communication and connectivity may include e-mail, web messaging, and telemedicine
Other
Functions of an EHR System as Defined by the IOM
Core Functions or Other Functions?
Patient support: includes everything from patient education materials to home monitoring to telehealth
Other
Functions of an EHR System as Defined by the IOM
Core Functions or Other Functions?
Administrative processes:
facilities and simplifies such processes as scheduling, prior authorizations, insurance verification; may also employ decision-support tools to identify eligible patient patients for clinical trials or chronic diseases management programs
Other
Functions of an EHR System as Defined by the IOM
Core Functions or Other Functions?
Reporting and population health management: establishes standardized terminology and data formats for public and private sector reporting requirements
Other
medical and nursing diagnoses
Health information and data
medication list
Health information and data
allergies
Health information and data
demographics
Health information and data
clinical narratives
Health information and data
laboratory test results
Results Management
manages all types of results electronically
Results management
laboratory test results, radiology procedure results
Results management
incorporates use of computerized provider entry, particularly in ordering medications
Order entry and support
employes computerized clinical decision-support capabilities such as reminders, alerts, and computer-assisted diagnosing
Decision Support
enables those involved in patient care to communicate effectively with each other and with the patient; technologies to facilitate communication and connectivity
Electronic communication and connectivity
e-mail, web messaging, and telemedicine
Electronic communication and connectivity
includes everything from patient education materials to home monitoring to telehealth
Patient Support
facilities and simplifies such processes as scheduling, prior authorizations, insurance verification; may also employ decision-support tools to identify eligible patient patients for clinical trials or chronic diseases management programs
Administrative processes
establishes standardized terminology and data formats for public and private sector reporting requirements
Reporting and population health management
Benefits of the Use of EHR Technology
- Improve health care quality, safety, and efficiency and reduce health disparities
- Engage patients and families in their health care
- Improve care coordination
- Improve population and public health
- Ensure adequate privacy and security of personal
health information
Secure website through which patients can electronically access their medical records
Patient Portal
Patient portal enables users to
○ Complete forms online
○ Schedule appointments
○ Communicate with providers
○ Request refills on prescriptions
○ Review test results
○ Pay bill
Key distinguishing characteristic of fully functional EHRs
Clinical Decision Support
Factors that Increase EHR Adoption
• Improve patient safety
• Reduce medical errors
• Reduce duplicate services
• Improve organizational efficiency
• Optimize reimbursement
• Complete locally and regionally
Barriers to Adoption:
Lack of capital or resources needed to develop, acquire, implement, and support a health care information system
Financial
Barriers to Adoption
Use and acceptance of changes in workflow
Organizational/Behavioral
Barriers to Adoption:
Work and technology needed to build system interfaces
Technical
“…tool to collect, track, and share past and current information about your health or the health of someone in your care.”
AHIMA 2016
Personal Health Records (PHR)
Not managed by a healthcare organization or provider and does not constitute a legal document of care but contains all pertinent health care information
Personal Health Records (PHR)
“…effective tool enabling patients to be active members of their own health care teams.”
Personal Health Records (PHR)
AHIMA stands for
American Health Information Management Association
Contents encoded in three systems EMR, EHR, and PHR
Patient Record Content
Information originates at the time of registration or admission
○ Name, address and telephone number
○ Insurance carrier
○ Policy number
○ Diagnoses and disposition at discharge
Patient Record Content: Identification Screen
Used as clinical and administrative document
Patient Record Content: Identification Screen
________ Identifies significant illness and operations and generally maintained over time by _______
Patient Record Content: Problem List; attending or primary care physician, or health care providers involved
Lists medicines prescribed and administer and medication allergies
Medical Record (Medication Administration Record - MAR)
Who are responsible for documenting and maintaining information in a Medical Record
Nursing Personnel
History Component describes?
● Any major illnesses and surgeries the patient had
● Family history of disease
● Patient health habits
● Current medications
● Information is provided by the patient
● Documented by physician or other care provider
What the physician found after the hands-on patient examination
Physical Component
Physical and History Component need?
● Document the initial patient assessment
● Provide basis for diagnosis and treatment
Made by physicians, nurses, therapists, social workers, and other staff members
Progress Notes
Reflect patient’s response to treatment; observations and plans for continued treatment
Progress Notes
What format should be followed on Progress Notes?
SOAP Format
Subjective findings
Objective findings
Assessment
Plan
SOAP Format stands for?
Subjective findings
Objective findings
Assessment
Plan
TRUE/FALSE: MTs are required to make progress notes.
False
Records opinions about the patient’s condition
Consultation Note or Report
Made by another health care provider at the request of the attending physician
May come from physicians and others inside or outside the organization
Consultation Note or Report
Directions, instructions, or prescriptions
Given to other members of the health care team regarding the patient’s:
○ Medications
○ Tests
○ Diets
○ Treatments, and others
Physician’s Orders
Responsibilities of the radiologist
○ Interpret images
○ Document interpretations or findings
Imaging & X-ray Reports
TRUE/FALSE: Imaging & X-ray Reports should be documented in a timely manner.
TRUE
Maintained in the radiology or imaging departments
Imaging & X-ray Reports
Contain results of tests conducted on body fluids, cells, and tissues
Laboratory Reports
Who documents lab results into the patient record
Laboratory Personnel
Documents any findings and treatment plans based on lab results
Physicians
TRUE/FALSE: Laboratory Results may or may not be available during treatment.
False (must be available)
Consent as a legal document
○ Admission
○ Treatment
○ Surgery
○ Release of information
Consent & Authorization Forms
Practitioner who provides treatment must obtain informed consent
Consent & Authorization Forms
TRUE/FALSE: Consent & Authorization Forms should be signed by the patient.
True
Describes any surgery performed
Operative Report
Lists the names of surgeons and assistants
Operative Report
Documents the information on the surgery performed
Surgeon
Operative report includes:
○ Name of surgeons
○ Assisting surgeons
○ Anesthesiologist
○ Date of surgery
○ Preoperative diagnosis
○ Postoperative diagnosis
○ Indications for surgery
Prepared by the surgeons, however some assisting surgeons are given this task
Describes tissue removed during any surgical procedure
Pathology Report
Diagnosis based on examination
Pathology Report
Documents the information for pathology reports
Pathologist
Summarizes the hospital stay
Discharge Summary
Summarizes the hospital stay including:
○ Reason for admission
○ Significant findings from tests
○ Procedures performed
○ Therapies provided
○ Responses to treatments
○ Condition at discharge
○ Instructions for medications, activity, diet and follow-up care
Documents the discharge summary
Attending Physician
