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Most medical errors occur...
Lost medical records, miscommunicated pt requests, unreadable information & mislabeled lab specimens
The institute of medicine suggests 8 core functions:
Health information, results management, order management, decision support, electronic communications, patient support, administrative processes & reporting & population management
What are Electronic Medical Records?
Computerized records of one physician's encounter with a patient over time.
What are Electronic Health Records?
Reflects data from all sources that have treated the individual.
SNOMED-CT is for:
clinical vocabulary designed to encompass all terms used in medicine and lab result contents
What is Current Procedural Terminology?
coding procedural terminology developed and maintained by the AMA
What is the Healthcare Common procedure Coding System?
contains codes for products, supplies & certain services not included in the CPT manual
make it possible to transfer data from systems such as laboratory or pharmacy systems
What Health Level Seven version 2.3+ is for:
scheduling, medical record & image management, patient administration, observation reporting, financial management, public health notification & patient care
Who is in charge of device-device connectivity?
Institute of Electrical and Electronics Engineers, Inc.
HL7 Version 2,3,1
specifically the Vaccines Administered & Manufacturers of Vaccines external code sets maintained by CDC,& NIP
Components of nonverbal communication
eye contact, body language, facial expression or symbolic expression
1. scheduling & information gathering, 2. check in, payment collection, 3. rooming, 4. checkout, 5. coding & billing & reviewing test results
EHR clinical toolsq
order tests, order medications, & send prescriptions, screen for illness, identify at risk patients & aid with disease management
primary benefits of hospital EHR
unlimited access to pt records, decreased waiting time for medication delivery & test results and increased efficiency & accuracy
process of obtaining & updating an accurate list of all patient's medications
benefits of PHR
1. elimination of errors made by patients filling out , 2. Allows patients with health concerns to travel with less worry, 3. ensures the safety of health records
internet based, tethered
individuals are granted access to phr through an outside organization, like insurance or providers
internet based, untethered
individuals are granted access to phr through a web based application with a user name and password
Internet based, networked & interoperable
allows transfer of the patient's providers, insurance or pharmacies (does not ensure privacy & security)
What Designated Record Set includes:
protected health information and is maintained by a covered entity
what is Treatment, Payment & Operations?
conditions that protected health information can be released without consent from the patient
Current Procedural Terminology
system of classification for services & procedures used in the outpatient setting
Digital Imaging and Communications in Medicine
standardized system used to transfer information between imaging systems
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