Unit 6 - EHR

Question 1

Why should we encourage the healthcare practitioners to move to an electronic system?

Answer 1

• improve the accuracy and quality of data recorded in a health record
• improve quality of care
• improve the efficiency of the health record service
• enhance healthcare practitioners’ access to a patient’s healthcare information
• contain healthcare costs

Question 2

True or False

many cases assume that an electronic healthcare record replaces the paper record

Answer 2

True

Question 3

What do you call a collection of computer-stored images of traditional health record documents that are scanned into a computer and images stored on optical disks?

Answer 3

Automated Health Records

AHR

in the 90’s, records mainly rely on document scanning onto optical disks. this addresses access, space, and control probs related to database records but does not address data input and output

Question 4

What term is used to describe automated systems based on document imaging or systems and is developed within a medical practice or health center?

Answer 4

Electronic Medical Record

EMR

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

Question 5

What record is a collection of health information for one patient linked by a patient identifer that includes the provision of care over a period of time?

provision of care = Medical alerts, Medication orders, Integrated data on px regis, Admission and financial details. Recording information from diff depts

Answer 5

Computer-based Patient Record

CPR

limited to inpatient facilities

Question 6

What record contains all personal health information belonging to an individual that extends beyong inpatient facilities?

information is entered and accessed electronically by multiple healthcare providers over a person’s lifetime

Answer 6

Electronic Health Record

EMR

Question 7

What record focuses on the total health of the patient wherein this goes beyond the data collected and there is sharing of information with other healthcare providers and organizations?

Answer 7

Electronic Health Records

Question 8

What record contains medical and treatment history of patiens in one practice or organizations and is also a digital version of paper charts?

Answer 8

Electronic Medical Records

Question 9

What record is an electronic record of health-related information on an individual that can be drawn from multiple sources while being managed, shared, and controlled by the individual (patient)?

Answer 9

Personal Health Record

parang EHR pero imbes na professionals mag-manage eh ikaw nagmamanage

Question 10

____ is a major issue that should be addressed before moving forward to automation. Without this, there will be no backbone of an effective and efficient health record system, whether manual or electronic.

Answer 10

Unique patient identification

Question 11

Accurate ____ is the backbone of aneffective and efficient health record system, whether manual or electronic

Answer 11

Unique patient identification

Question 12

Besides unique patient identification, what are the other possible issues that may be present b4 implementing a successful EHR?

Answer 12

• Clinical data entry issues and lack of standard terminology
• Resistance to comp technology and lack of computer literacy
• Strong resistance to change
• High cost of comps and systems
• Information availability upon request
• Privacy and confidentiality concerns
• Quality of electronic healthcare information and accuracy of data entries
• Lack of staff w/ enuff knowledge of disease classification
• Manpower issues
• Environmental issues
• Involvement of clinicians and hospital administrator

Question 13

What are the safeguards which may need to be addressed before a successful EHR implementation?

Answer 13

• Efficient backup system available
• Contingency plans for disaster recovery
• Securing workstations and password requirement
• Access to authorized ppl onli
• Audit controls

Question 14

Benefits of the use of EHR

Answer 14

1. Improve healthcare
2. Engage ppl in their healthcare
3. Improve care coordination
4. Improve popu & pubhealth
5. Ensure adequate privacy and security of personal health information

Question 15

What do u call a secure website through which patients can access their medical records electronically?

Answer 15

Patient portal

this enables users to complete forms online, sched appointments, communicate w/ providers, request meds, review tets, pay bills

Question 16

Factors that increase EHR Adoption

Answer 16

• Improve px safety
• Reduce medical errors
• Reduce duplicate services
• Improve organizational efficiency
• Optimize reimbursement
• Complete locally and regionally

Question 17

What are the components of EHR?

Answer 17

• Px ID/Registration attributes
• Information from diff depts
• Scanned docs/previous medical records
• DIsease classification/indexing
• Clinical data treatment/doc visits

Question 18

What are the core functions of EHR?

Answer 18

• Health information and data
• Results management
• Order entry and support
• Decision support

Question 19

What are the barriers present that hinders the successful adoption of EHR?

Answer 19

• Financial
• Organizational/Behavioral
• Technical

Question 20

What record has information about your health or the health of someone in your care and is not managed by a healthcare organization or provider?

Answer 20

Personal Health Record

PHR

Question 21

True or False

PHRs may be managed by doctors and does not constitute a legal document of care but contains all pertinent healthcare info

Answer 21

False

not managed by docs, d rest is true

Question 22

What are the components of a patient record?

Answer 22

• Identification Screen
• Problem List
• Medical Record
• History and Physical components
• Progress notes
• Consultation note or Report
• Physician’s orders
• Imaging & Xray Reports
• Laboratory Reports
• Consent and Authorization forms
• Operative report
• Pathology report
• Discharge summary

Question 23

Identify the component of patient record content

• Information originates at the time of registration or admission
• Name, address and telephone number
• Insurance carrier
• Policy number
• Diagnoses and disposition at discharge
• Used as clinical and administrative document

Answer 23

Identification Screen

Question 24

Identify the component of patient record content

• Identifies significant illness and operations
• Generally maintained over time by attending or primary care physician, or Health care providers involved

Answer 24

Problems List

signs and symptoms

Question 25

# Identify the component of patient record content - known also as Medication Administration Record (MAR) - Lists medicines prescribed and administered - Lists medication allergies - Nursing personnel are responsible for documenting and maintaining information

Answer 25

Medical Record

Question 26

# Identify the component of patient record content - Any major illnesses and surgeries the patient had - Family history of disease - Patient health habits - Current medications - Information is provided by the patient - Documented by physician or other care provider

Answer 26

History component

Question 27

# Identify the component of patient record content What the physician found after the hands-on px examination

Answer 27

Physical component ## Footnote Physical and History components both document the initial px assessment and provide basis for diagnosis and treatment

Question 28

# Identify the component of 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 - SOAP format – (Subjective findings, Objective findings, Assessment, Plan)

Answer 28

Progress Notes

Question 29

# Identify the component of 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

Answer 29

Consultation Note or Report

Question 30

# Identify the component of patient record content - Directions, instructions, or prescriptions - Given to other members of the health care team regarding the patient’s Medications, Tests, Diets, Treatments, and others

Answer 30

Physician's Orders

Question 31

# Identify the component of patient record content Contains images that are: * Documented in a timely manner * Maintained in the radiology or imaging departments

Answer 31

Imaging and X-ray reports

Question 32

# Identify the component of patient record content - Contain results of tests conducted on body fluids, cells, and tissues - Laboratory personnel document lab results into the patient record - Must be available during treatment - Physicians document any findings and treatment plans based on lab results

Answer 32

Laboratory Reports

Question 33

# Identify the component of patient record content - Consent as a legal document (Admission, Treatment, Surgery, Release of information) - Practitioner who provides treatment must obtain this first - Signed by patients

Answer 33

Consent and Authorization Forms

Question 34

# Identify the component of patient record content - Describes any surgery performed - Lists the names of surgeons and assistants - Surgeons - Document the information

Answer 34

Operative Report

Question 35

# Identify the component of patient record content - Describes tissue removed during any surgical procedure - Diagnosis based on examination - Pathologist documents the information

Answer 35

Pathology Report

Question 36

# Identify the component of patient record content - Summarizes the hospital stay including: Reason for admission, Significant findings from tests, Procedures performed, Therapies provided, Responses to treatments, Condition at discharge, Instructions for medications, activity, diet and follow-up care - Attending physician – documents the discharge summary

Answer 36

Discharge summary ## Footnote placed on top of the medical record; serves as the synopsis of the px's stay

Question 37

Records that are photographed or saved are called ____. ## Footnote photos r highly dependent on quality

Answer 37

Automated Health Record | AHR ## Footnote done since kodak times lmao (90's~ nga)

Question 38

A single consultation which may be pharmaceutical, imaging, or etc. may be classified as what type of record?

Answer 38

Electronic Medical Record ## Footnote isa-isa lng = medical record. compilation of EMRs = EHR

Question 39

# True or False Not all patients can access their respective patient portals.

Answer 39

True