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Patient Records > Storage and Retention > Flashcards

Storage and Retention Flashcards

1
Q

who is initiating computerized medical record keeping?

A

The Provincial and Federal government

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2
Q

what is the ultimate end result?

A

one record–one patient

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3
Q

what are the advantages of electronic medical record keeping?

A
  • freed up space
  • time consuming to covert existing paper records to electronic records.
  • frustrating glitches
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4
Q

how is the electronic medical record(EMR) used in the examining room?

A
  • discussion of up-to-date lab results, consultations, and tests.
  • Dr.’s document health info using open text or fully structured EMR.
  • patients can sign the computer screen making for a true “paperless” office.
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5
Q

Provide examples of EMR components the physician would complete during a physical exam.

A 
flow sheet
past medical history
medication profile
problem list 
allergy alert 
lab/diagnostic test
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6
Q

List the electronic safeguards that EMR systems in Alberta must have

A
  • only authorized personnel can access the EMR
  • each user is assigned a unique identifier in EMR
  • different access levels
  • the EMR is password protected.
  • audit trail in place.
  • electronic signature can be authenticated.
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7
Q

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

A
  • open text, information is entered on a “ blank page”.
  • can use templates such as SOAP
  • fully structured (fill in blanks)
  • information is entered into defined fields.
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8
Q

What is a tickler file?

A

-a reminder system
traditional-file folders, binder ( color coding, should be visible, checking becomes routine)
Computerized - pop up messages

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9
Q

What is archiving?

A

-taking a file from active use and storing it in a secondary location or “medium”

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10
Q

Define active, inactive, and closed files.

A

Active: still in use.
Inactive: patient not seen for a predesignated period of time/not sure if patient has left practice.
Closed: clients leave the practice or die.

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11
Q

When are inactive and closed files stored and for how long?

A
  • Can be stored off location.
  • in Alberta, a period of 10 years from dat e of separation from hospital or 2 years past the date of majority, which ever is longer.
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12
Q

How are archived paper records filed?

A
  • files have to be able to be retrieved quickly.
  • can be organized by year or range of years.
  • may use same filing systems as active charts.
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13
Q

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

A

YES!

-usually moved to another medium.

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14
Q

Name and explain four archiving option

A
  • microfilm
  • microfiche
  • CD Rom- electronic generated information
  • Magnetic tage - temporary storage medium for computer generated information( scanned from paper. Often used for backing up computer information.
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15
Q

What is a centralized system of storage?

A
  • used in private practice.
  • in hospitals - Health records department.
  • all records - inpatient & outpatient kept in one file, one location.
  • often purged (centralized records)
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16
Q

What is a decentralized system of storage?

A
  • parts of patient records reside outside central area.
  • hospitals have clinics that store charts separately (diabetes/cast clinics)
  • some records kept separate due to sensitive nature (abortion clinic/AIDS)
17
Q

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

A
  • pulled for reference.
  • review
  • waiting for lab results or letter to add to chart.
  • dictation
  • billing
18
Q

The Provincial and Federal government are the ones who are..

A

initiating computerized medical record keeping

19
Q

one record–one patient

A

is the ultimate end result and initialized plan

20
Q
  • freed up space
  • time consuming to covert existing paper records to electronic records.
  • frustrating glitches
A

are the advantages of electronic medical record keeping

21
Q
  • discussion of up-to-date lab results, consultations, and tests.
  • Dr.’s document health information using open text or fully structured EMR.
  • patients can sign the computer screen making for a true “paperless” office.
A

Is how the electronic medical record (EMR) used in the examining room.

Patient Records (4 decks)

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