Test 2 Review Flashcards
what are 3 basic principles of documentation in an EHR?
- use specific language and avoid speculation
- specific observations or conversations
- objective facts, no opinions
what are some of the items that are important in a chart for meaningful use?
CPOE, drug allergy checks, eprescribing, medication list, demographics, vital signs
what are 4 things documentation should include?
date and time, reason for encounter, history and physical (H&P), and lab results
chief complaint
reason for encounter
progress notes
response to treatment, change in treatment, or diagnosis change
- mainly for physicians and consultants
- jobs such as social worker and dietician use this area for notes
non-compliance
never use this term because someone may not do what they are told because of low health literacy
basic parts of a chart
medical history, H&P, physician orders, progress and nursing notes, test results, flowcharts, and discharge summary
when should a discharge plan begin?
when the patient is admitted
how does a facility get reimbursed?
with documentation supporting intensity of evaluation and treatment based on levels 1-4: based on complexity of decision making and severity of disease
upcoding
billing someone for a level higher than what their disease is considered
what is informed consent?
the physician explains the risks and benefits and alternatives, the patient can either change their mind or agree, or the guardian can make the decision if the patient can’t
how are EHR entries authenticated?
date and time, and first and last name with credentials
how are corrections made or late entries added?
cross out the mistake with one line, note it as an error with name and credentials
-late entries must be noted as late and with the time of the actual observation, not the entry
why are interdisciplinary teams important?
often one professional can’t meet all needs, as system is becoming more specialized and increased knowledge and skills needed
multidisciplinary team
various disciplines caring for one patient but that is the only common goal, there is no “real” communication
interdisciplinary team
IDT
have shared goal to optimize care and quality of life and they meet regularly to discuss patient
inter-professional team
latest description of cross functional teams with knowledge of contribution
-basically newer word for interdisciplinary
why did EHRs come into play?
to better organize and use health data and to make it easier to share patient data with other facilities
interoperability
ability of different information technology systems and software applications to communicate, exchange data, and use information
computerized physician order entry
CPOE
allows providers to prescribe, order tests, and give instructions electronically
order-set
predefined list of orders that are most common to a particular diagnosis
-can be efficient but are sometimes ineffective because they don’t account for unique circumstances
clinical decision support
CDS
- uses data to help providers make decisions regarding patient care
ex) checking medications against patient data to ensure allergies or conflict
meaningful use
the facility will actually collect data, not just “have it”
-“are you going to put the system to use?”
HITECH Act of 2009
incentivized the use on EHR through rewards and penalties
Health Information Exchange
HIE
sharing data between EHRs
outcomes of using EHR
it is costly and can result in lost efficiency due to training, but improved 30 day mortality, inpatient mortality, and length of stay
-worsened readmission rates
why no significant improvements with EHR?
not enough time to acclimate
tech not made to best fit the way they work
not enough places use it
HIPAA
Healthcare Information Portability and Accountability Act
- 1st universal code to protect privacy
- gives the patient access to their record and ability to fix mistakes
- patient has right to know how info is shared and can’t give info to certain people
comorbid
2 past diseases
multimorbid
currently living with multiple diseases
what is nomenclature
how you choose names for things and the process
ex) switching smartphone types doesn’t always work because the data is not mapped out the same
medico
legal standard of care
structured data
results in a file that are searchable and graphable
unstructured data
data that is not in certain fields of the chart such as progress notes etc
what is an audit function
authority can track who is looking in an EHR and when they were in it
difference between EHR and EMR
EHR is the “big data,” the culmination of all visits
EMR is contained in one visit
4 Benefits of EHR
track (tracking data), identify (seeing who’s due for screenings, etc), monitor (monitor patients at home care) and improve (improve quality of care)
patient portal
online medical chart patient can access with a username and password
what are the benefits of an EHR from a patient’s perspective?
less time filling out paperwork, less duplicate testing, reliable reminders, convenience, and online charts
what is the item called that allows patient access to their own information?
patient portal
SOAP method of charting
S-subjective data as described by patient
O-objective data derived from exam and test results
A-assessment by physician
P-plan for further investigation to diagnose, treat, and educate patient
