Paper Records
How to start a paper chart entry
What is date and time?
Subjective information
What is information that cannot be measured, only stated by the patient
The HITECH act
What is use technology meaningful
Continuity of Care
What is the the smooth continuation of care from one provider to another
The source oriented record is based on what
Give examples
What is the source of the information
Laboratory
Progress notes
Radiology
Hospital
Consultations
How to close out a paper chart entry
What is name and credential?
Objective information
What is information that can be measured with tools
Meaningful use definition
What is using technology in a way to benefit patients
Prognosis
What is the expected health outcome
The Problem oriented record is based on what
Give examples
What is problem solving
The database
Problem list
Treatment plan
Progress notes
Organize in numeric consecutive style
423
324
474
342
324
342
423
474
History of smoking is charted in which part of the chart?
What is social history
Meaningful use examples
E-prescribing
Alerting of allergies
Computerized Physician/Provider order entry
Laboratory integration
Differential diagnosis
What is the probability of one diagnosis over another diagnosis
What information is found in the S section of SOAP progress notes?
Subjective information
Organize in terminal digit filing
12-34-04
12-05-06
12-09-04
06-87-05
What is
12-09-04
12-34-04
06-87-05
12-05-06
3 main advantages of the EHR
What is
Easy storage of patient information
Available to multiple users at the same time
More efficient claims processing
Chief complaint
What is concise account of patients symptoms in patients own words
What information is found in the A section of SOAP progress notes?
Assessment - physical exam
How to organize alphabetically
Jason K. Jeremy
Siouxsie Banshee
Jason D. Jeremy
Catherine Sunrise
What is
Banshee, Siouxsie
Jeremy, Jason D.
Jeremy, Jason K.
Sunrise, Catherine
History of hospitalization is charted in which part of the chart
What is past medical history?
The relationship between the HITECH act and meaningful use
What is the HITECH act defines meaningful use and gives examples on how to use technology in a meaningful manner
What is died, moved away, or fired provider
What information is found in the P section of SOAP progress notes?
Plan - What the treatment will be