Week 13- Electronic health and medical records Flashcards
5 basic steps for filing
Conditioning, Releasing, Indexing and Coding, Sorting, Sorting and filing
Medicare and Medicaid patient records must be kept for _____ years
10 years
How should medical records be discarded?
Shredded by professional company
digital charts to be used within a facility
EMR- electronic medical records
includes EMR and other info to be used in between facilities
EHR- electronic health records
What should be used to make a correction in an EHR/EMR?
Addendum
Who can authorize forms?
Patient, minors parent/legal gaurdian, or POA
grouping related papers together, removing paper clips & stapling
conditioning
making a form to be filed
releasing
determining where to place a file in the records
indexing and coding
ordering papers in a filing structure
sorting and filing
records controlled solely by the patients
PHR (personal health record)
history of present illness
chief complaint
guidelines imposed by HITECH Act 2009 to improve quality, safety and reduce health disparities
Meaningful Use