54 terms

Electronic Health Records exam (NHA) 2011

Personal Health record
maintained and owned by the patient
Electronic Health Record
data from ALL sources that have treated an individual
Electronic Medical Records
computerized records of ONE physician's encounter with a patient over time
Institute of Medicine
defines EHR to function: Health info. and data, results, orders, decision support, electronic communications, patient support, administrative, reporting and population mgt.
total conversion
may be costly; allows all patient data to be converted at once while office still sees patients
incremental conversion
gradual change to EHR, lower cost, smoother transition and less impact on office, however paper is still used and not all patient data available
hybrid conversion
uses combination of paper and electronic forms of data
clinical templates
allow doctors to document patient encounters into EHR on structured form
clinical vocabularies
common definitions for medical terms that ease communication by decreasing ambiguity
clinical vocabulary designed to encompass ALL terms used in medicine (Systemized Nomenclature of Medicine Clinical Terms): also used for anatomy, nursing, diagnosis/ problem lists, content of lab results, units of measure & immunizations (CVX, MVX)
terms and codes used for electronic exchange of lab results & clinical observations (Logical Observation Identifiers Names & Codes)
thesaurus database of medical terms
ICD-9 and ICD-10
international classification of diseases developed by the World Health Orgnanization (WHO)
procedural code system
ICD-9 vs. ICD-10
(International Classifications of Diseases)
ICD-9 has 3-5 alphanumeric for inpatient and outpatients with 3-4 numeric procedure codes; ICD-10 has 3-7 alphanumeric for inpatient & outpatients with 7 alphanumeric procedure codes
current procedural terminology; maintained by the AMA (american medical assoc.) descriptive terms & codes for reporting medical services & procedures performed in an outpatient setting (evaluation, anesthesia, surgery, lab, medicine)
Healthcare Common Procedure Coding System: codes for products, supplies & services not included in CPT maintained by the Centers for Medicare/Medicaid Services (CMS)
Centers for Medicare/Medicaid Services
Health Level 7: messaging standards for scheduling, medical record/image mgt., pt. admin., observations, financial mgt., public health notification and pt. care; also for pt. demographics
National council for Prescription Drug Programs: for retail pharm. transactions
Institute of Electrical & Electronics Engineers: device to device connectivity
Digital Imaging & Communications in Medicine: gets image info to workstations
vaccines administered
manufacturers of vaccines
Center for Disease Control
National Immunization Program
Use Federal drug terminologies from FDA
Active ingredient
FDA established names & UNII codes (Unique Ingredient Identifier Codes)
Manufactured Dosage
FDA/CDER data standards manual
Drug product
FDA National Drug Codes (NDC)
Medication Package
FDA Standards manual
Label Section Headers
LOINC Clinical Structured Product Labeling (SPL)
Special Populations
Drug Classifications
Dept. of Veteran Affairs National Drug File Reference Terminology (NDF-RT)
Clinical Drug
National Library of Medicine's Rx Norm
Health Insurance Portability & Accountability Act
Title I: health insurance reform: rights for the transfer of elctronic healthcare data
Title II: administration & simplication standards put privacy and security in place to ensure confidential PHI
Patient chart includes:
Vital Signs, Chief Complaint, Progress Notes, Past Medical Hx, Family Hx, Social Hx, allergies, medications, HPI (hx of present illness), ROS (review of systems), Diagnosis & assessment, treatment plan
a feature of most EHR's-- Advantages: auto checks for drug interactions, safety checks, and will send alerts for potential Rx problems
Primary benefits of EHR
unlimited access to pt. info., decreased waiting for medication delivery and test results, increased efficiency & accuracy
Computerized Physician Order Entry: app to enter pt. care info and provides support tools which results in improved pt. & outcomes
electronic medication administration record & scheduling: to track meds going in and out of a pharmacy/hospital, etc. (helps with errors and ADE-adverse drug events)
5 rights of eMars
right patient, right medication, right dose, right time, right route
medication reconciliation
process of obtaining and updating an accurate list of all patient meds
personal health record: a patient's lifelong medical hx in electronic format (personal hx, allergies, immunizations, surgeries, etc.). This does NOT replace legal records of providers
Types of PHR
1. Computer based, stand alone: downloaded software transferred to a portable memory device in order to access from another location
2. Internet based, tethered: access provided by insurance co. or provider; limited editing ownership maitained by access organization
3. Internet based, untethered: web based app involving username/password, editing as needed
4. Internet based, networked/interoperable: networked between insurance, pharmacies, other healthcare organizations, continually updated--disadvantage: does not ensure complete privacy/security
companies that process health info and execute elctronic transactions
designated record set: group of info. that includes PHI and is maintained by a covered health entity
electronic protectected health information
Notice of Privacy Practices
these are conditions regarding treatment, payment and operations--conditions under which PHI can be released without consent
defined as: name, address, Names of relatives & employers, SS#, Ph and fax #, email address, Health plan id#, account #, fingerprints, website address, MR#, serial numbers of vehicles and photos
Health information technology
Unified Medical Language System
electronic resource containing various medical terms
range of motion: referring to patient joints--can be limited or full or even "no" which means a lack of movement in the joint alltogether