Unit 6 - Electronic Health Records Flashcards by Khris Manalo

Q

Collection of computer-stored images of traditional health record documents
- Scanned into computer
- stored in optical disks

a. Automated Health Record (AHR)
b. Electronic Medical Record (EMR)
c. Computer-based Patient record (CPR)
d. Electronic Health record (EHR)

A

a

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Q

Describe automated systems based on document imaging or systems

a. Automated Health Record (AHR)
b. Electronic Medical Record (EMR)
c. Computer-based Patient record (CPR)
d. Electronic Health record (EHR)

A

b.

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Q

Developed within a medical practice or health center

a. Automated Health Record (AHR)
b. Electronic Medical Record (EMR)
c. Computer-based Patient record (CPR)
d. Electronic Health record (EHR)

A

b

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Q

Include patient identification details, medications and
prescription generation, laboratory results, and healthcare information recorded by the doctor

a. Automated Health Record (AHR)
b. Electronic Medical Record (EMR)
c. Computer-based Patient record (CPR)
d. Electronic Health record (EHR)

A

b

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Q

Collection of health information for one patient linked by a patient identifier

a. Automated Health Record (AHR)
b. Electronic Medical Record (EMR)
c. Computer-based Patient record (CPR)
d. Electronic Health record (EHR)

A

c

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Q

Medical alerts, Medication orders, Integrated data on a patient’s registration, Admission and financial details, Recording information from nurses, laboratory, radiology, and pharmacy

a. Automated Health Record (AHR)
b. Electronic Medical Record (EMR)
c. Computer-based Patient record (CPR)
d. Electronic Health record (EHR)

A

c.

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Q

Contains all personal health information belonging to an individual

a. Automated Health Record (AHR)
b. Electronic Medical Record (EMR)
c. Computer-based Patient record (CPR)
d. Electronic Health record (EHR)

A

d

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Q

Entered and accessed electronically by healthcare providers over the person’s lifetime

a. Automated Health Record (AHR)
b. Electronic Medical Record (EMR)
c. Computer-based Patient record (CPR)
d. Electronic Health record (EHR)

A

d.

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Q

Extends beyond acute inpatient situations

a. Automated Health Record (AHR)
b. Electronic Medical Record (EMR)
c. Computer-based Patient record (CPR)
d. Electronic Health record (EHR)

A

d.

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Q

In EHR: Idealy, the EHR should reflect the entire _____ of an individual across his or her lifetime including data from multiple providers from a variety of healthcare settings

A

health history

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Q

Digital version of paper charts

a. ELECTRONIC HEALTH RECORDS (EHR)
b. ELECTRONIC MEDICAL RECORDS (EMR)

A

b

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Q

Contains medical and treatment history of patients in or
practice or organization

a. ELECTRONIC HEALTH RECORDS (EHR)
b. ELECTRONIC MEDICAL RECORDS (EMR)

A

b

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Q

Easily identify who are due for screenings or checkups

a. ELECTRONIC HEALTH RECORDS (EHR)
b. ELECTRONIC MEDICAL RECORDS (EMR)

A

b

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Q

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 healthcare organization

a. ELECTRONIC HEALTH RECORDS (EHR)
b. ELECTRONIC MEDICAL RECORDS (EMR)

A

b

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Q

Enable clinicians to track data over time

a. ELECTRONIC HEALTH RECORDS (EHR)
b. ELECTRONIC MEDICAL RECORDS (EMR)

A

b

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Q

Focus on the total health of the patient

a. ELECTRONIC HEALTH RECORDS (EHR)
b. ELECTRONIC MEDICAL RECORDS (EMR)

A

a

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Q

Going beyond standard clinical data collected

a. ELECTRONIC HEALTH RECORDS (EHR)
b. ELECTRONIC MEDICAL RECORDS (EMR)

A

a

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Q

Share information with other health care providers and
organizations

a. ELECTRONIC HEALTH RECORDS (EHR)
b. ELECTRONIC MEDICAL RECORDS (EMR)

A

a

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Q

Decision-support capabilities

a. ELECTRONIC HEALTH RECORDS (EHR)
b. ELECTRONIC MEDICAL RECORDS (EMR)

A

a

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Q

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

a. ELECTRONIC HEALTH RECORDS (EHR)
b. ELECTRONIC MEDICAL RECORDS (EMR)

A

a

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Q

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 individua

a. ELECTRONIC HEALTH RECORDS (EHR)
b. ELECTRONIC MEDICAL RECORDS (EMR)
c. PERSONAL HEALTH RECORD

A

c

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Q

Unique ________ is a major issue that should be addressed before moving forward to automation

A

Patient identification

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Q

It is the backbone of effective and efficient health record system, whether manual or electronic

A

Patient Identification

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Q

Identify the possible issues:

Adopting a standard, comprehensive vocabulary
Develop a data dictionary

a. Clinical data entry issues and lack of standard terminology
b. Resistance to computer technology and lack of computer literacy
c. Strong resistance to change by any healthcare providers

A

a

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Identify the possible issues: o Some prefer to write by hand o Some are still not proficient in using computers a. Clinical data entry issues and lack of standard terminology b. Resistance to computer technology and lack of computer literacy c. Strong resistance to change by any healthcare providers

b

Identify the possible issues: o The change to entering patients’ health record data via a computer or other electronic device may be difficult a. Clinical data entry issues and lack of standard terminology b. Resistance to computer technology and lack of computer literacy c. Strong resistance to change by any healthcare providers

c

Identify the possible issues: o Requires intensive training of healthcare practitioners a. Clinical data entry issues and lack of standard terminology b. Resistance to computer technology and lack of computer literacy c. Strong resistance to change by any healthcare providers

c

Identify the possible issues: o Need to compare the current system costs plus perceived costs for the new EHR system a. High cost of computers and computer systems funding limitations b. Concern by providers ac to whether information will be available on request c. Concerns about privacy, confidentiality and the quality and accuracy of electronically generated information d. Quality of electronic healthcare information and accuracy of data entries

a

Identify the possible issues: o Information should always be readily available a. High cost of computers and computer systems funding limitations b. Concern by providers ac to whether information will be available on request c. Concerns about privacy, confidentiality and the quality and accuracy of electronically generated information d. Quality of electronic healthcare information and accuracy of data entries

b

Identify the possible issues: o Information can be accessed more efficiently a. High cost of computers and computer systems funding limitations b. Concern by providers ac to whether information will be available on request c. Concerns about privacy, confidentiality and the quality and accuracy of electronically generated information d. Quality of electronic healthcare information and accuracy of data entries

b

Identify the possible issues: o Retention schedules a. High cost of computers and computer systems funding limitations b. Concern by providers ac to whether information will be available on request c. Concerns about privacy, confidentiality and the quality and accuracy of electronically generated information d. Quality of electronic healthcare information and accuracy of data entries

c

Identify the possible issues: o How information is to be retrieved a. High cost of computers and computer systems funding limitations b. Concern by providers ac to whether information will be available on request c. Concerns about privacy, confidentiality and the quality and accuracy of electronically generated information d. Quality of electronic healthcare information and accuracy of data entries

c

Identify the possible issues: o Accuracy and validity of the original source data, Reliability, Completeness, Legibility, Currency and timeliness o Accessibility a. High cost of computers and computer systems funding limitations b. Concern by providers ac to whether information will be available on request c. Concerns about privacy, confidentiality and the quality and accuracy of electronically generated information d. Quality of electronic healthcare information and accuracy of data entries

d

Identify the possible issues: o Limited coding training programs a. Lack of staff with adequate knowledge of disease classification systems b. Manpower issues c. Environmental issues d. Involvement of clinicians and hospital administrators

a

Identify the possible issues: o Selected people who do not have a medical background a. Lack of staff with adequate knowledge of disease classification systems b. Manpower issues c. Environmental issues d. Involvement of clinicians and hospital administrators

a

Identify the possible issues: o lack of staff with adequate skills a. Lack of staff with adequate knowledge of disease classification systems b. Manpower issues c. Environmental issues d. Involvement of clinicians and hospital administrators

b

Identify the possible issues: o Staff may be available, but their skills may not be adequate a. Lack of staff with adequate knowledge of disease classification systems b. Manpower issues c. Environmental issues d. Involvement of clinicians and hospital administrators

b

Identify the possible issues: o Well-trained workforce a. Lack of staff with adequate knowledge of disease classification systems b. Manpower issues c. Environmental issues d. Involvement of clinicians and hospital administrators

b

Identify the possible issues: o Electrical wiring and supply of electricity a. Lack of staff with adequate knowledge of disease classification systems b. Manpower issues c. Environmental issues d. Involvement of clinicians and hospital administrators

c

Identify the possible issues: o Amount and quality of space needed for computers and other equipment a. Lack of staff with adequate knowledge of disease classification systems b. Manpower issues c. Environmental issues d. Involvement of clinicians and hospital administrators

c

Identify the possible issues: o Thorough understanding of clinical data a. Lack of staff with adequate knowledge of disease classification systems b. Manpower issues c. Environmental issues d. Involvement of clinicians and hospital administrators

d

Identify the possible issues: o Their specifications and input a. Lack of staff with adequate knowledge of disease classification systems b. Manpower issues c. Environmental issues d. Involvement of clinicians and hospital administrators

d

Identify the possible issues: o Willingness to collaborate and share data a. Lack of staff with adequate knowledge of disease classification systems b. Manpower issues c. Environmental issues d. Involvement of clinicians and hospital administrators

d

5 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

Determine wat **core function** of EHR: Includes medical and nursing diagnoses, a medication list, allergies, demographics, clinical narratives, and laboratory test results a. Health information and data b. Results management c. Order entry and support d. Decision support

a

Determine wat **core function** of EHR: Manages all types of results (for example, laboratory test results, radiology procedure results) electronically a. Health information and data b. Results management c. Order entry and support d. Decision support

b

Determine wat **core function** of EHR: incorporates use of computerized provider order entry, particularly in ordering medications a. Health information and data b. Results management c. Order entry and support d. Decision support

c

Determine wat **core function** of EHR: Employs computerized clinical decision-support capabilities such as reminders, alerts, and computer-assisted diagnosing a. Health information and data b. Results management c. Order entry and support d. Decision support

d

List the 4 Core functions of EHR - H R O D

Health Information and data Results management Order entry and support Decision support

Determine wat **other function** of EHR: Enables those involved in patient care to communicate effectively with each other and with the patient; technologies to facilitate communication and connectivity may include email, web messaging, and telemedicine a. Electronic communication and connectivity b. Patient support c. Administrative processes d. Reporting and population health management

a

Determine wat **other function** of EHR: Includes everything from patient education materials to home monitoring to telehealth a. Electronic communication and connectivity b. Patient support c. Administrative processes d. Reporting and population health management

b

Determine wat **other function** of EHR: Facilities and simplify such processes as scheduling, prior authorizations, insurance verification; may also employ decision support tools to identify eligible patients for clinical trials or chronic disease management program a. Electronic communication and connectivity b. Patient support c. Administrative processes d. Reporting and population health management

c

Determine wat **other function** of EHR: Establishes standardized terminology and data formats for public and private sector reporting requirements a. Electronic communication and connectivity b. Patient support c. Administrative processes d. Reporting and population health management

d

It is a secure website through which patients can electronically access their medical records

Patient Portal

Where patients: - Schedule appointment - Communicate with providers - Request refills on prescriptions - Review Test results - Pay bill

Patient portal

3 Barriers to Adoption F O T

Financial Organizational or Behavioral Technical

Determine what Barrier to Adoption: Lack of capital or resources needed to develop, acquire, implement, and support a healthcare information system a. Financial b. Organizational or Behavioural c. Technical

a

Determine what Barrier to Adoption: Use and acceptance of changes in workflow a. Financial b. Organizational or Behavioural c. Technical

b

Determine what Barrier to Adoption: Work and technology needed to build system interfaces a. Financial b. Organizational or Behavioural c. Technical

c

It is a record which is not managed by a healthcare organization or provider

Personal health Record

TRUE OR FALASE Personal health Record *constitute* a legal document of care

FALSE it **does not constitute** but contains all pertinent healthcare information

Determine what Patient record content: Where information originates at the time of registration or admission a. Identification Screen b. Problem list c. Medical Record d. History & Physical e. Progress notes f. Consultation note or report g. Physician’s order h. Imaging & X-ray reports i. Laboratory reports j. Consent & Authorization forms k. Operative report l. Pathology report m. Discharge summary

a

Determine what Patient record content: Used as clinical and administrative document a. Identification Screen b. Problem list c. Medical Record d. History & Physical e. Progress notes f. Consultation note or report g. Physician’s order h. Imaging & X-ray reports i. Laboratory reports j. Consent & Authorization forms k. Operative report l. Pathology report m. Discharge summary

a

Identification Screen includes 4 informations N I P D

Name, address, telephone number # Insurance carrier policy # Diagnoses and Disposition at discharge

Determine what Patient record content: ● Identifies significant illness and operations ● Generally maintained over time a. Identification Screen b. Problem list c. Medical Record d. History & Physical e. Progress notes f. Consultation note or report g. Physician’s order h. Imaging & X-ray reports i. Laboratory reports j. Consent & Authorization forms k. Operative report l. Pathology report m. Discharge summary

b

Determine what Patient record content: o By attending or primary care physician o Health care providers involved a. Identification Screen b. Problem list c. Medical Record d. History & Physical e. Progress notes f. Consultation note or report g. Physician’s order h. Imaging & X-ray reports i. Laboratory reports j. Consent & Authorization forms k. Operative report l. Pathology report m. Discharge summary

b

Determine what Patient record content: ● AKA Medication Administration Record (MAR) ● Lists medicines prescribed and administered ● Lists medication allergies a. Identification Screen b. Problem list c. Medical Record d. History & Physical e. Progress notes f. Consultation note or report g. Physician’s order h. Imaging & X-ray reports i. Laboratory reports j. Consent & Authorization forms k. Operative report l. Pathology report m. Discharge summary

c

Determine what Patient record content: Nursing personnel are responsible for documenting and maintaining information a. Identification Screen b. Problem list c. Medical Record d. History & Physical e. Progress notes f. Consultation note or report g. Physician’s order h. Imaging & X-ray reports i. Laboratory reports j. Consent & Authorization forms k. Operative report l. Pathology report m. Discharge summary

c

Determine what Patient record content: o Document the initial patient assessment o Provide basis for diagnosis and treatment a. Identification Screen b. Problem list c. Medical Record d. History & Physical e. Progress notes f. Consultation note or report g. Physician’s order h. Imaging & X-ray reports i. Laboratory reports j. Consent & Authorization forms k. Operative report l. Pathology report m. Discharge summary

d

Determine what 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 a. Identification Screen b. Problem list c. Medical Record d. History & Physical e. Progress notes f. Consultation note or report g. Physician’s order h. Imaging & X-ray reports i. Laboratory reports j. Consent & Authorization forms k. Operative report l. Pathology report m. Discharge summary

e

Determine what Patient record content: SOAP format - most common o Subjective findings o Objective findings o Assessment o Plan a. Identification Screen b. Problem list c. Medical Record d. History & Physical e. Progress notes f. Consultation note or report g. Physician’s order h. Imaging & X-ray reports i. Laboratory reports j. Consent & Authorization forms k. Operative report l. Pathology report m. Discharge summary

e

Meaning of SOAP in Progress notes

Subject findings Objective findings Assessment Plan

Determine what 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 a. Identification Screen b. Problem list c. Medical Record d. History & Physical e. Progress notes f. Consultation note or report g. Physician’s order h. Imaging & X-ray reports i. Laboratory reports j. Consent & Authorization forms k. Operative report l. Pathology report m. Discharge summary

f

Determine what Patient record content: ● Directions, instructions, or prescriptions ● Given to other members of the healthcare team regarding the patient’s a. Identification Screen b. Problem list c. Medical Record d. History & Physical e. Progress notes f. Consultation note or report g. Physician’s order h. Imaging & X-ray reports i. Laboratory reports j. Consent & Authorization forms k. Operative report l. Pathology report m. Discharge summary

g

Determine what Patient record content: ● Responsibilities of the radiologists ● Documented in a timely manner ● Maintained in the radiology or imaging departments a. Identification Screen b. Problem list c. Medical Record d. History & Physical e. Progress notes f. Consultation note or report g. Physician’s order h. Imaging & X-ray reports i. Laboratory reports j. Consent & Authorization forms k. Operative report l. Pathology report m. Discharge summary

h

Determine what Patient record content: ● Contain results of tests conducted on body fluids, cells, and tissues a. Identification Screen b. Problem list c. Medical Record d. History & Physical e. Progress notes f. Consultation note or report g. Physician’s order h. Imaging & X-ray reports i. Laboratory reports j. Consent & Authorization forms k. Operative report l. Pathology report m. Discharge summary

i

Under Laboratory Reports: Who is the who document lab result into the patient record

Laboratory personnel

Under Laboratory Reports: Who is the one who document any findings and treatment plans based on lab results

Physicians

Determine what Patient record content: ● Practitioner who provides treatment must obtain informed consent ● Signed by patients a. Identification Screen b. Problem list c. Medical Record d. History & Physical e. Progress notes f. Consultation note or report g. Physician’s order h. Imaging & X-ray reports i. Laboratory reports j. Consent & Authorization forms k. Operative report l. Pathology report m. Discharge summary

j

Determine what Patient record content: ● Describes any surgery performed ● Lists the names of surgeons and assistants ● Surgeons a. Identification Screen b. Problem list c. Medical Record d. History & Physical e. Progress notes f. Consultation note or report g. Physician’s order h. Imaging & X-ray reports i. Laboratory reports j. Consent & Authorization forms k. Operative report l. Pathology report m. Discharge summary

k

Determine what Patient record content: ● Describes tissue removed during any surgical procedure ● Diagnosis based on examination a. Identification Screen b. Problem list c. Medical Record d. History & Physical e. Progress notes f. Consultation note or report g. Physician’s order h. Imaging & X-ray reports i. Laboratory reports j. Consent & Authorization forms k. Operative report l. Pathology report m. Discharge summary

L

Determine what Patient record content: ● Summarizes the hospital stay a. Identification Screen b. Problem list c. Medical Record d. History & Physical e. Progress notes f. Consultation note or report g. Physician’s order h. Imaging & X-ray reports i. Laboratory reports j. Consent & Authorization forms k. Operative report l. Pathology report m. Discharge summary

m

WHo documents the discharge summary? a. Nurse b. Pathologist c. Attending Physician d. General Physician

C