Chapter 5
Converting paper-based records to electronic health records requires the ______ of paper records into the electronic database
Scanning
What should be done when an error is found in an electronic health record?
overwrite the original entry
erase the original entry
do not address the error
flag the error to notify users of the correct data location
flag the error to notify users of the correct data location
Name one type of communication used in the medical office.
Word processing. • E-mail. • Computer networks. • The Internet. • Wireless communication.
The instructions that tell the hardware what to do
Computer software
Name three advantages of Electronic Health Records
Easy and quick updating of medical records. • Automatic verification of medications. • Fewer medical misinterpretations due to poor handwriting. • Higher level of data security by use of passwords, encryption, and frequent backup of medical data; minimum backup requirement is to perform a daily backup, with some practices conducting backups throughout the work shift. • Greater amount of time spent in patient care as a result of less time spent updating medic
Which of the following is a similarity between electronic health records and paper-based records?
Errors may occur in both.
Both may be accessed from multiple locations.
Both provide automatic verification of medications.
Both allow for quick and easy updating of medical records.
Errors may occur in both.
There are many advantages to converting from paper-based medical records to ______ health records.
electronic
This type of computers are used in large businesses, hospitals, large clinics, and government organizations; store massive databases, which many users can access at the same time.
Mainframe
What is another name for patient medical records?
Chart or file
Name some challenges of Electronic Health Records
Initial cost and contract fees can be too costly for healthcare providers. Updating of system. Ongoing training. Scanning of hardcopy documents into the system. Time spent by the provider on capturing medical information from the patient and entering it into the EHR is time taken away from patient care. • Scribes are being trained and employed to meet the need for entering data into the EHR
After patient encounters, the new electronic medical document should be reviewed and _____________.
released to the patient
saved to a hard drive
proofread for errors
printed as a hard copy
proofread for errors
Double Jeopardy!!!!
EHR stand for
Electronic Health Records
This type of computers have many of the features of a mainframe but are not as big or nearly as expensive.
• Minicomputers:
Chart notes. • History and physical. • Referral and consultation letters. • Medical reports. • Correspondence. • Clinical forms. • Medication list. • Advance Directive and other legal forms
Name steps in making Corrections in an Electronic Health Record
Add an amendment to clarify/correct the original entry. • Add a late entry to add missing or omitted information. • Add an addendum to insert new information in an original electronic medical record entry
A(n) ______ should be used to make a correction in an electronic medical record.
amendment
PMH stand for
Past Medical History
This the most powerful computers available. • Mainframe computers: used in large businesses, hospitals, large clinics, and government organizations; store massive databases, which many users can access at the same time.
Supercomputers
Name three reason for maintaining medical records
Main source of information for coordinating and carrying out patient care among all providers involved with the patient. • A record of medical necessity. • A record of the quality of care. • Ensures communication and continuity of care from one medical facility to another. • Legal record for the practice. • Main record to ensure appropriate reimbursement. • A source of data for research purposes.
Types of Abbreviations used in the medical field
Weights and measures. • Designations of times and methods. • Terms typically found in chart notes.
Which of the following is true regarding amendments?
may be completed as time permits
should be electronically signed
stamped only with the year
if a hard copy was printed, it does not need to be corrected
should be electronically signed
PE stand for
Physical Exam
This the science of designing the work environment to meet the needs of the human body
Ergonomics
Double Jeopardy!!!!
Describe the process of making corrections in paper based medical records
Use the strike-through feature in the word processing program or draw a single line through the incorrect statements in the medical record (making sure the inaccurate material is still legible). • Enter the word error or mistaken entry next to the deleted statement. • Write your initials and the date next to the correction. • Enter the correct information above or below the inserted line in the medical record.
What does SOAP stand for
Subjective, Objective, Assessment and Plan