Informatics History
The primary goal of informatics is to transform this into a format clinicians and patients can use for treatment.
What is data?
This type of record is managed and controlled entirely by the individual patient.
What is a Personal Health Record (PHR)?
HIPAA protection is lost if you choose to post your own health information here.
What is social media?
The common medical saying is: "If you did not document it, it ___ ___ ___."
What is "did not happen"?
This acronym stands for the global system used to classify diseases.
What is ICD (International Classification of Diseases)?
During the 1980s "Paper Era," retrieving a single medical record could take this long.
What is hours to days?
This is a digital version of a paper chart containing history within a single practice only.
What is an Electronic Medical Record (EMR)?
This law protects the confidentiality of records specifically within educational institutions
What is FERPA?
When charting, being "objective" means you should document only what you do these three things.
What are see, hear, or feel?
The ability of different EHR systems to "talk" to each other and work together is called this.
What is interoperability?
This 1990s era involved recording information on paper and then digitizing it into a computer.
What is the Scanning Era?
Unlike an EMR, this record is designed to reach beyond the original organization to share info with labs and specialists
What is an Electronic Health Record (EHR)?
Under HIPAA’s "Right to Access," a provider must generally provide copies of your records within this many days.
What is 30 days?
While the patient owns the information inside, this entity actually owns the physical medical record.
What is the healthcare facility?
This acronym refers to the process of a provider entering orders into a computer rather than writing them on paper.
What is CPOE (Computerized Provider Order Entry)?
This specific electronic system mentioned in the notes could detect adverse drug reactions and alert doctors to abnormal values.
What is HELP?
This type of PHR is manually filled in by the patient rather than being linked to a hospital system.
What is a Standalone PHR?
This HIPAA right allows a patient to see a list of how their information was shared, excluding treatment or payment.
What is the Right to Accounting?
This characteristic of high-quality data ensures that information is recorded in a standardized way every time.
What is consistency?
Stage 2 of Meaningful Use focuses on these, including e-prescribing and lab results
What are Advanced Clinical Processes?
Telehealth is specifically helpful for chronic disease patients because it helps reduce these expensive and risky events.
What are hospital readmissions?
In an emergency with an unconscious patient, an EHR allows a clinician to immediately see these life-threatening details.
What are allergies?
This insurance giant experienced a massive breach in 2015, affecting nearly 79 million records.
Who is Anthem Blue Cross Blue Shield?
Legally, altering a medical chart to hide a mistake is considered this level of violation.
What is a criminal offense?
This is the process of creating an accurate list of all patient medications and comparing them against new orders.
What is Medication Reconciliation?