RES: MODULE 3 PART 1 Flashcards
Healthcare providers need to keep accurate records system to store information about patients and the use of these records can help them make certain diagnoses, recommendations, and plan of
care.
HEALTH RECORDS
Collections of patient’s health data or information
HEALTH RECORDS
A digital, repository or form of storage of the health status of the patient
ELECTRONIC HEALTH RECORD (EHR)
Traditionally, patients depend on their healthcare
providers regarding their health records
HEALTH RECORDS
the use of modern technology in compiling in healthcare information between medical practitioners for a more holistic approach for healing.
Healthcare information system
A process that connects the patients with the healthcare providers, patients to the resources and different services
case management information systems
types of healthcare organization information systems
- case management information systems
- communication systems
- core business systems
- computer based patient record
This system is directed toward ensuring that patients receive best possible care
case management information systems
Includes numerous assessments, planning, implementation, follow up’s and evaluating outcomes
case management information systems
General benefit: Reduce risks, decrease cost and ensure quality
case management information systems
A good communication is critical in having a good healthcare
communication systems
Continue to evolve to improve the delivery of healthcare and enhance productivity
communication systems
What are the systems communciation systems
- provider to provider
- provider to patient systems
3.internal messaging
Promote interaction among healthcare providers and patients
communication systems
example for provider to provider
insurance companies
example for provider to patient systems
telemedicine
example for internal messaging
emergency notifications
The trust of the system is for the maximization of resources and minimization of waste without the reduction of quality in the patient care
core business systems
some health records are still paper-based while other components are electronics
hybrid environment
A healthcare organization will have multiple information systems that must be available to share information.
hybrid environment
Used in 1980’s by the Institute of Medicine (IOM) further described it as “a system specifically designed to support users through the availability of complete and accurate data, practitioner reminders and alerts, clinical decision support, links to bodies of medical knowledge and, other aids”
computer described patient record (CPR)
What are the 5 common business systems
- Admissions
- Discharge and transfers
- Financial systems
- Acuity systems
- Scheduling systems
whatare the 3 main goals?
- Improve communication across care providers
- Improve chronic care patient management
- Reduce unnecessary hospital utilization
May benefit clinicians and patients from faulty, incorrect and misinterpreted data
order entry systems
Refers to the request, instructions and intentions to perform a specific tasks
order entry systems
Instead of making traditional handwritten transcriptions, doctors or clinicians can place orders using this system
order entry systems
These are patient-centered which contains observations, interventions and outcomes noted by the care team
patient care support systems
A meaningful engagement of patient and physician stakeholders must be solicited in a well- coordinated manner with broad healthcare system that supports full execution of patient-centered processes
patient care support systems
A digital record that provides comprehensive health information about your patients
electronic health records
Are built to share information with others healthcare providers and organizations such as laboratories, specialists, medical imaging facilities, pharmacies, emergencies and workplace clinics
electronic health records
They contain information from all clinicians involved in a patient’s care
electronic health records
key components of ehr
- Administrative and Billing Data
- Patient Demographics
- Progress Notes
- Vital Signs
- Medical Histories
- Diagnoses
- Medications
- Immunization Dates 9. Allergies
- Radiology Images
- Laboratory and Tests Results
Handwritten documentations used in the hospital settings or different clinical settings
manual record systems
Can be accessed through online or application within the facility’
automated record systems
whatare the advantages of manual record systems
- Lowstart-up costs
- Trainingofstaffis
simple - Requires less
technically trained staff
4Paper records are available because there is no downtime
what are the disadvantage of manual record systems
- Retrieval of information is not
easily customized - Handwritten
information can be
illegible - Difficult to abstract information
- Undocumented services are not
usually discovered
supply EHR and other applications with data
SOURCE SYSTEMS
what are the 2 parts of administrative and financial systems?
- REGISTRATION, ADMISSION,
DISCHARGE AND TRANSFER (R- ADT) - PATIENT (PFSs) FINANCIAL SYSTEMS
Register admission
services, patients for or outpatient capturing
REGISTRATION, ADMISSION,
DISCHARGE AND TRANSFER (R- ADT)
administrative and financial systems: Tracks when patients are admitted and opens an account for them
REGISTRATION, ADMISSION,
DISCHARGE AND TRANSFER (R- ADT)
administrative and financial systems: Tracks all transfers within the hospital
REGISTRATION, ADMISSION,
DISCHARGE AND TRANSFER (R- ADT)
administrative and financial systems:Closes the account when a patient is discharged
REGISTRATION, ADMISSION,
DISCHARGE AND TRANSFER (R- ADT)
Frequently called billing system in a physician practice, aid revenue cycle management (RCM)
PATIENT (PFSs) FINANCIAL SYSTEMS
Refers to the entire process of creating, submitting, analyzing, and obtaining payment for healthcare services
PATIENT (PFSs) FINANCIAL SYSTEMS
Ancillary or departmental systems are also called:
Clinical departmental systems
Serves primarily to manage the department
ANCILLARY OR DEPARTMENTAL SYSTEMS
Providing key clinical data for the EHR
ANCILLARY OR DEPARTMENTAL SYSTEMS
what are the 3 main departments of ancillary or departmental systems?
- Laboratory Information System
- Radiology Information System
- Pharmacy Information System
ancillary or departmental systems:
- receives order for a lab test
- generates a work list for specimen collection, labeling, and accessioning
- retrieve results from an auto-analyzer
- perform quality control
- maintain an inventory of equipment and supplies needed
Laboratory information system
ancillary or departmental systems:
- Performs similar functions
- receives order, scheduling
- notifying hospital personnel or the patient
- tracking the performance of the procedure and its output
- tracking preparation of the report
- performing quality control
- maintaining an inventory of equipment and supplies
radiology information system
ancillary or departmental systems:
- receives order for a drug
- checking for contraindications
- compounding any drugs requiring special preparation
- dispensing the drug in the appropriate dose and for appropriate route of administrations
- maintains inventory
- supporting staffing
pharmacy information system
