The Shift to Electronic Documentation - Documenting and Reporting

Question 1

To enhance communication among health care providers and thus patient safety, Canadian Health Infoway had a mandate to partner with jurisdictions for the development and implementation of an ___ health ___ (EHR) to support effective health care delivery for Canadians.

Answer 1

electronic / record

Question 2

EHR

Answer 2

Electronic health record

Question 3

Digital version of patient data that is found in traditional paper records.

Answer 3

Electronic health record (EHR)

Question 4

Used increasingly to refer to a longitudinal (lifetime) record of all health care encounters for an individual patient.

Answer 4

Electronic health record (EHR)

Question 5

The legal record that describes a single encounter or visit created in hospitals and outpatient health care settings that is the source of data for the EHR.

Answer 5

EMR

Question 6

EMR

Answer 6

Electronic medical records

Question 7

Provide a longitudinal or lifetime patient record by linking all patient data from previous health care encounters.

Answer 7

Electronic health record (EHR)

Question 8

• Include a problem list indicating current clinical problems for each health care encounter, the number of occurrences associated with all past and current problems, and the current status of each problem
• Require the use of accepted, standardized measures to evaluate and record health status and functional levels

Answer 8

Electronic health record (EHR)

Question 9

• Provide a method for documenting the clinical reasoning or rationale for diagnoses and conclusions that allows clinical decision making to be tracked by all providers who access the record
• Support confidentiality, privacy, and audit trails
• Provide continuous access to authorized users at any time

Answer 9

Electronic health records (EHR)

Question 10

• Allow multiple health care providers access to customized views of patient data at the same time
• Support links to local or remote information resources such as databases using the Internet or intranet resources based within an organization
• Support the use of decision analysis tools

Answer 10

Electronic health record (EHR)

Question 11

• Support direct entry of patient data by physicians
• Include mechanisms for measuring the cost and quality of care
• Support existing and evolving clinical needs by being flexible and expandable

Answer 11

Electronic health record (EHR)

Question 12

The promise of the ___ is twofold: (1) making a positive impact on the quality of patient care through interprofessional collaboration with improved data availability and information synthesis, and (2) improving patient safety through the use of clinical decision support.

Answer 12

Electronic health record (EHR

Question 13

Provides access to a patient’s health record information at the time and place that clinicians need it.

Answer 13

Electronic health record (EHR)

Question 14

A unique feature of an ___ is its ability to integrate all patient information into one record, regardless of the number of times a patient enters a health care system.

Answer 14

electronic health record (EHR)

Question 15

An ___ also includes results of diagnostic studies that may include diagnostic images (e.g., X-ray film or ultrasound images).

Answer 15

electronic health record (EHR)