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ch.11 summary

Terms in this set (26)

name and discuss the two types patients records
paper record and electronic health record.
Electronic health record (EHR)
electronic health record that conforms to nationally recognized interoperability standard and can be created, managed, and consulted by authorized by clinicians and staff from more than one healthcare organization.
Electronic medical record (EMR)
electronic medical record that can be created, gathered, managed and consulted by authorized clinicians and staff within one healthcare organization.
several reasons that accurate health records are important
so that the correct care can be given, also helps ensure continuity of care between providers so that no lapse in treatment occurs. and serves as indication and proof in court that certain treatment and procedures were performed.help aid researchers with statistical information.
subjective information
provided by the patient. patient's address, social security number, insurance and discription of what he or she is experiencing.
objective information
information provided by the provider questions and observations made during the examination.
who own the health record
the provider own the physical health record, but the patient controls the information contain in it.
explain how the American Recovery and Reinvestment Act (ARRA) of 2009 applies to the healthcare industry
known as economic stimulus package, was meant to promote economic recovery, the health information technology aspects of the bill provide slightly more than $31 billion for the healthcare infrascture and EHR investment. the sections of the ARRA that pertain to healthcare are known as the Health Information Technology for Economic and Clinical Health (HITECH).
define meaningful use and relate it ti the healthcare industry
meaningful use, defined simply, means that the providers must show that they are using EHR technology in ways that can be measured significantly in quality and quantity. if the providers meet the meaningful use requirements, they will qualify for incentive payments.
list three main components of meaningful use legislation
(1)use of certified EHR in a meaningful manner, such as e-prescribing;(2)use of certified EHR technology for electronic exchange of health information to improve quality of healthcare; and (3) use of certified EHR technology to submit clinical quality reports, procedure and diagnosis codes, surveys, and other measures.
advantages of the EHR include
reduction of errors, costs, staffing needs, legible documentation, easy accessibility, and less physical storage space than paper records.capabilities include specialty practice compaonents,appointment scheduling features, prescription writers, medical billing systems, charge capture, eligibility verification, referral management, laboratory order integration, patient portals, and many verity depending on the system.
disadvantages of the EHR include
lack of capital, fear of something new, startup costs, and space for equipment.
importance of nonverbal communication with patients when using EHR system
eye contact are critical, body language must indicate that the medical assistant is open to and listening to the patient's concerns, not just concentrating on date entry.
backup systems , as well as transfer, destruction, and retention of health record related to the EHR
the provider must have backup in case office is without power for a significant amount of time. the EHR system can be set to automatically back up the information at a specific time.this means that a minimum amount of data would be lost if the power went out.options include external hard drive, full server backup, and online backup.
most medical offices record are classified in three ways
active, inactive, and closed. the process of moving a file from active to inactive is call purging. providers have an obligation to retain patient records. the records of any patient covered by Medicare or Medicaid must be kept at least 10 years.
when and how health record information to be release; discuss health information exchanges (HIEs)
extremily careful when releasing any medical information;patient must sign a release form to be given to any third party.request must be hand written .pay particular retention to records release requests involving a minor.
three kind of HIE
direct exchange, query based exchange, and consumer-mediciated exchange and the implementation of HIE veries from state to state.
first methods of organizing a patients paper medical record;
Source-oriented medical record (SOMR)
Source-oriented medical record (SOMR) categorizes the content by it source, such as provider, laboratory, radiology, hospital, and consultation. within each source category, the content is arranged in reverse chronologic order so that the most recent content is view first.
second methods of organizing a patients paper medical record; problem-oriented medical record (POMR)
problem-oriented medical record (POMR) is categoriezes each of the patient's problems and elaborates on the findings and treatment plans for all concerns.detailed progress notes are kept for each individual problem. this method addresses each of the patient's concerns separately, whereas a source-oriented record may address all problems and concerns at one time, usually covering one to three patient concerns per office visit. the POMR helps ensure that individual problems are all addressed.
documentation information in an EHR and a paper health record
EHR involves using radio buttons, drop-down menus, and free text boxes when documenting in paper health record the entry will always start with the date in the MM/DD/YYYY format.all entries must be written in black or blue ink and follow the format designated by the healthcare facility.
create a handwritten correction to a health record
a line should be drawn through the error, the correction inserted above or immediately after, and the person making the correction should write his or her initials or signature and the date below the correction.errors made while using an EHR are corrected in the usual way; however, an error discovered in an entry at a later date is corrected in the same manner as a handwritten entry.
discuss dictation and transcription, and discuss transfer, destruction, and retention of medical records as related to paper records.
with the increase of EHRs and voice recognition software, there is decreased need for transciption. can be done with handwritten notes, or more likely from machine dictation.accuracy and speed are important. as with EHR paper record are also classified as active, inactive, and closed.
Identify filing equipment and filing supplies needed to create, store, and maintain medical record
office space availability; structural considerations; cost of the space and equipment; size, type, and volume of the medical records; confidentiality requirements; retrieval speed; fire protection; and cost should all be considered when choosing filing equipment. filing equipment includes; drawer files,horizontal shelf files, rotary circular files, compactable files, automated files, and card files. filing supplies include divider guides, outguides, file folders, and labels.
index rule on organizing patient's health record
five step;(1)the paper are conditioned, which is the preparatory stage of filing.(2)the documents are released, which means they are ready to be filed because they have been reviewed or read and sometype of mark has been placed on the document to indicate.(3)the documents are indexed,which involves deciding where each document should be files and coding it with some type of mark on the paper indicating that dicision.(4)sorting involves placing the files in filing sequence.(5)the actual filing and sorting of the documents is the last step.
organization of files, and health-related correspondence
when record is not in actual use, should only be in filing cabinet or on shelf. health-related correspondence, including general correspondance, should be filed appropriately. practice management files are usually divided into active and paid accounts. papers that do not warrant an individual folder are place in the miscellaneous folder. follow-up files are frequently called "tickler files". transitory (termporary) files can be helpful for material with no permanent value.
patient education, as well as legal and ethical issues, related to the health record
the primary goal of all healthcare facilities is to provide efficient. highqyality patient care. patient worry about the security of their information and lawsuits can be filed when patients discover that an unauthorized person has accessed their protected health information (PHI). the authority to release information from the health record lies solely with the patient unless such a release is required by law through a subpoena duces tectum.
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