UNIT 6 (EHR) Flashcards
A Collection of computer-stored images of traditional health record documents.
Automated Health Records (AHR)
It can Scanned into a computer and Stored on optical disks.
Automated Health Records (AHR)
It Describes automated systems based on document imaging or systems
Electronic Medical Record (EMR)
Developed within a medical practice or health center
Electronic Medical Record (EMR)
Include patient identification details, medications and prescription generation, laboratory results, and healthcare information recorded by the doctor
Electronic Medical Record (EMR)
It is the Collection of health information for one patient linked by a patient identifier
Computer-based Patient Record (CPR)
-Medicalalerts
-Medicationorders
-Integrated data on a patient’s registration -Admission and financial details
-Recording information from nurses, laboratory, radiology, and pharmacy
Computer-based Patient Record (CPR)
Contains all personal health information belonging to an individual
Electronic Health Record (EHR)
It Entered and accessed electronically by healthcare providers over the person’s lifetime and Extends beyond acute inpatient situations
Electronic Health Record (EHR)
True or 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
A Digital version of paper charts and Contains medical and treatment history of patients in one practice or organization
Electronic Medical Records (EMR)
It Enables clinicians to
̶ Track data overtime
̶ Easily identify who are due for screenings or check ups
̶ Check their patients
̶Monitor and improve overall quality of care within the practice
Electronic Medical Records (EMR)
• Focus on the total health of the patient
̶ Going beyond standard clinical data collected
̶ Share information with other health care providers and organizations
̶ Decision-supportcapabilities
Electronic Health Records (EHR)
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 health care 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
Major Issue:
What is a major issue that should be addressed before moving forward to automation.
Unique patient identification
Major Issue:
What is the backbone of an effective and efficient health record system, whether manual or electronic?
Accurate Patient Identification
True or False: Other possible issues are Clinical data entry issues and lack of standard terminology.
True
True or False: Other possible issues are Resistance to computer technology and lack of computer literacy because Some prefer to write by hand and Some are still not proficient in using computers.
True
True or False: Other Possible Issues are Strong resistance to change by many healthcare providers because it Requires intensive training of healthcare practitioners. It is also The change to entering patients’ health record data via a computer or other electronic device may be difficult.
True
Other Possible Issues is High cost of computers and computer systems and funding limitations
It Needs to compare the current system costs plus perceived costs for the new EHR system
Other Possible Issues is the Concern by providers as to whether information will be available on request
The Information should always be readily available and the Information can be accessed more efficiently
Other Possible Issues are Concerns about privacy, confidentiality and the quality and accuracy of electronically generated information.
It is the Retention schedules and How information is to be retrieved
Other Possible Issues are Quality of electronic healthcare information and accuracy of data entries
-Accuracy and validity of the original sourcedata -Reliability
-Completeness
-Legibility
-Currency and timeliness
-Accessibility
Other Possible Issue is Lack of staff with adequate knowledge of disease classification systems
It is Limited coding training programs and Selected people who do not have a medical background
Other Possible Issues is Manpower issues – lack of staff with adequate skills
-The Staff may be available, but their skills may not be adequate.
-Well-trained workforce
Other Possible Issues are Environmental issues
̶ Electrical wiring and supply of electricity
̶ Amount and quality of space needed for computers and other equipment
Other Possible Issues are Involvement of clinicians and hospital administrators
̶ Thorough understanding of clinical data
̶ Their specifications and input
̶ Willingness to collaborate and share data
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
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
This is to Secure website through which patients can electronically access their medical records
Patient Portal
Enable users to:
Complete forms online, Schedule appointments, Communicate with providers, Request refills on prescriptions, Review test results, Paybills
Patient Portal
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:
What is the Lack of capital or resources needed to develop, acquire, implement, and support a health care information system?
Financial
Barriers to Adoption:
It is Use and acceptance of changes in workflow.
Organizational or Behavioral
It is Work and technology needed to build system interfaces.
Technical
According to this organization, “…tool to collect, track, and share past and current information about your health or the health of someone in your care.”
AHIMA (2016)
It is Not managed by a health care organization or provider and Does not constitute a legal document of care But contains all pertinent healthcare information.
Personal Health Records (PHR)
According to this organization, “…effective tool enabling patients to be active members of their own health care teams.”
AHIMA (2016)
What is the Information originates at the time of registration or admission?
̶ Name,addressandtelephonenumber
̶ Insurancecarrier
̶ Policynumber
̶ Diagnosesanddispositionatdischarge
Identification Screen
Used as clinical and administrative document
Identification Screen
It Identifies significant illness and operations
Problem List
It is Generally maintained over time.
̶ By attending or primary care physician, or Health care providers involved
Problem List
A.K.A. Medication Administration Record (MAR)
Medical Record
Lists medicines prescribed and administered and Lists medication allergies
Medical Record
Nursing personnel are responsible for documenting and maintaining information
Medical Record
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
History or Physical?
Physical component states
-Document the initial patient assessment
-Provide basis for diagnosis and treatment
History or Physical?
Both components
Made by physicians, nurses, therapists, social workers, and other staff members and it Reflect patient’s response to treatment; observations and plans for continued treatment
Progress Notes
SOAP format:
̶ Subjective findings
̶ Objective findings
̶ Assessment
̶ Plan
It Records opinions about the patient’s condition
Consultation Note or Report
It Made by another health care provider at the request of the attending physician and May come from physicians and others inside or outside the organization.
Consultation Note or Report
Directions, instructions, or prescriptions
Physician’s Orders
Given to other members of the health care team regarding the patient’s
̶ Medications
̶ Tests
̶ Diets
̶ Treatments,andothers
Physician’s Orders
It is the Responsibilities of the radiologist which Interpret images and Document interpretations or findings.
Imaging and X-ray Reports
Documented in a timely manner and Maintained in the radiology or imaging departments
Imaging and X-ray Reports
Contain results of tests conducted on body fluids, cells, and tissues.
Laboratory Reports
It Documents lab results into the patient record.
Laboratory personnel
Must be available during treatment
Laboratory Reports
It will Document any findings and treatment plans based on lab results
Physicians
True or False: Practitioner who provides treatment must obtain informed consent and signed by patients.
True
Consent as a legal document ̶ Admission
̶ Treatment
̶ Surgery
̶ Releaseofinformation
Consent and Authorization Forms
This Describes any surgery performed and Lists the names of surgeons and assistants.
Operative Report
In Operative Report who will Document the information?
Surgeons
Describes tissue removed during any surgical procedure and Diagnosis based on examination
Pathology Report
In Pathology Report who will documents the information?
Pathologist
Who will documents the discharge summary?
Attending physician
