Unit 6 - EHR Flashcards
Why should we encourage the healthcare practitioners to move to an electronic system?
- improve the accuracy and quality of data recorded in a health record
- improve quality of care
- improve the efficiency of the health record service
- enhance healthcare practitioners’ access to a patient’s healthcare information
- contain healthcare costs
True or False
many cases assume that an electronic healthcare record replaces the paper record
True
What do you call a collection of computer-stored images of traditional health record documents that are scanned into a computer and images stored on optical disks?
Automated Health Records
AHR
in the 90’s, records mainly rely on document scanning onto optical disks. this addresses access, space, and control probs related to database records but does not address data input and output
What term is used to describe automated systems based on document imaging or systems and is developed within a medical practice or health center?
Electronic Medical Record
EMR
Includes patient identification details, medications and prescription generation, laboratory results, and healthcare information recorded by the doctor
What record is a collection of health information for one patient linked by a patient identifer that includes the provision of care over a period of time?
provision of care = Medical alerts, Medication orders, Integrated data on px regis, Admission and financial details. Recording information from diff depts
Computer-based Patient Record
CPR
limited to inpatient facilities
What record contains all personal health information belonging to an individual that extends beyong inpatient facilities?
information is entered and accessed electronically by multiple healthcare providers over a person’s lifetime
Electronic Health Record
EMR
What record focuses on the total health of the patient wherein this goes beyond the data collected and there is sharing of information with other healthcare providers and organizations?
Electronic Health Records
What record contains medical and treatment history of patiens in one practice or organizations and is also a digital version of paper charts?
Electronic Medical Records
What record is an electronic record of health-related information on an individual that can be drawn from multiple sources while being managed, shared, and controlled by the individual (patient)?
Personal Health Record
parang EHR pero imbes na professionals mag-manage eh ikaw nagmamanage
____ is a major issue that should be addressed before moving forward to automation. Without this, there will be no backbone of an effective and efficient health record system, whether manual or electronic.
Unique patient identification
Accurate ____ is the backbone of aneffective and efficient health record system, whether manual or electronic
Unique patient identification
Besides unique patient identification, what are the other possible issues that may be present b4 implementing a successful EHR?
- Clinical data entry issues and lack of standard terminology
- Resistance to comp technology and lack of computer literacy
- Strong resistance to change
- High cost of comps and systems
- Information availability upon request
- Privacy and confidentiality concerns
- Quality of electronic healthcare information and accuracy of data entries
- Lack of staff w/ enuff knowledge of disease classification
- Manpower issues
- Environmental issues
- Involvement of clinicians and hospital administrator
What are the safeguards which may need to be addressed before a successful EHR implementation?
- Efficient backup system available
- Contingency plans for disaster recovery
- Securing workstations and password requirement
- Access to authorized ppl onli
- Audit controls
Benefits of the use of EHR
- Improve healthcare
- Engage ppl in their healthcare
- Improve care coordination
- Improve popu & pubhealth
- Ensure adequate privacy and security of personal health information
What do u call a secure website through which patients can access their medical records electronically?
Patient portal
this enables users to complete forms online, sched appointments, communicate w/ providers, request meds, review tets, pay bills
Factors that increase EHR Adoption
- Improve px safety
- Reduce medical errors
- Reduce duplicate services
- Improve organizational efficiency
- Optimize reimbursement
- Complete locally and regionally
What are the components of EHR?
- Px ID/Registration attributes
- Information from diff depts
- Scanned docs/previous medical records
- DIsease classification/indexing
- Clinical data treatment/doc visits
What are the core functions of EHR?
- Health information and data
- Results management
- Order entry and support
- Decision support
What are the barriers present that hinders the successful adoption of EHR?
- Financial
- Organizational/Behavioral
- Technical
What record has information about your health or the health of someone in your care and is not managed by a healthcare organization or provider?
Personal Health Record
PHR
True or False
PHRs may be managed by doctors and does not constitute a legal document of care but contains all pertinent healthcare info
False
not managed by docs, d rest is true
What are the components of a patient record?
- Identification Screen
- Problem List
- Medical Record
- History and Physical components
- Progress notes
- Consultation note or Report
- Physician’s orders
- Imaging & Xray Reports
- Laboratory Reports
- Consent and Authorization forms
- Operative report
- Pathology report
- Discharge summary
Identify the component of patient record content
- Information originates at the time of registration or admission
- Name, address and telephone number
- Insurance carrier
- Policy number
- Diagnoses and disposition at discharge
- Used as clinical and administrative document
Identification Screen
Identify the component of patient record content
- Identifies significant illness and operations
- Generally maintained over time by attending or primary care physician, or Health care providers involved
Problems List
signs and symptoms
Identify the component of patient record content
- known also as Medication Administration Record (MAR)
- Lists medicines prescribed and administered
- Lists medication allergies
- Nursing personnel are responsible for documenting and maintaining information
Medical Record
Identify the component of patient record content
- 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
History component
Identify the component of patient record content
What the physician found after the hands-on px examination
Physical component
Physical and History components both document the initial px assessment and provide basis for diagnosis and treatment
Identify the component of patient record content
- Made by physicians, nurses, therapists, social workers, and other staff members
- Reflect patient’s response to treatment; observations and plans for continued treatment
- SOAP format – (Subjective findings, Objective findings, Assessment, Plan)
Progress Notes
Identify the component of patient record content
- Records opinions about the patient’s condition
- Made by another health care provider at the request of the attending physician
- May come from physicians and others inside or outside the organization
Consultation Note or Report
Identify the component of patient record content
- Directions, instructions, or prescriptions
- Given to other members of the health care team regarding the patient’s Medications, Tests, Diets, Treatments, and others
Physician’s Orders
Identify the component of patient record content
Contains images that are:
- Documented in a timely manner
- Maintained in the radiology or imaging departments
Imaging and X-ray reports
Identify the component of patient record content
- Contain results of tests conducted on body fluids, cells, and tissues
- Laboratory personnel document lab results into the patient record
- Must be available during treatment
- Physicians document any findings and treatment plans based on lab results
Laboratory Reports
Identify the component of patient record content
- Consent as a legal document (Admission, Treatment, Surgery, Release of information)
- Practitioner who provides treatment must obtain this first
- Signed by patients
Consent and Authorization Forms
Identify the component of patient record content
- Describes any surgery performed
- Lists the names of surgeons and assistants
- Surgeons
- Document the information
Operative Report
Identify the component of patient record content
- Describes tissue removed during any surgical procedure
- Diagnosis based on examination
- Pathologist documents the information
Pathology Report
Identify the component of patient record content
- Summarizes the hospital stay including: Reason for admission, Significant findings from tests, Procedures performed, Therapies provided, Responses to treatments, Condition at discharge, Instructions for medications, activity, diet and follow-up care
- Attending physician – documents the discharge summary
Discharge summary
placed on top of the medical record; serves as the synopsis of the px’s stay
Records that are photographed or saved are called ____.
photos r highly dependent on quality
Automated Health Record
AHR
done since kodak times lmao (90’s~ nga)
A single consultation which may be pharmaceutical, imaging, or etc. may be classified as what type of record?
Electronic Medical Record
isa-isa lng = medical record. compilation of EMRs = EHR
True or False
Not all patients can access their respective patient portals.
True
