advantages of the EHR
disadvantages of the EHR
-expense -downtime -difficulties associated with change -lack of integration -patients fear their records will be posted on the Internet
why do you keep medical records accurate
1)financial reimbursement 2)provide statistical information that is helpful to researchers 3)legal protection to those who provide care to patients 4)help provider provide the best possible care to patient
Who owns the health record?
Provider who generated the information
method of organizing the health record
SOMR POMR chronological order
How are burns coded?
by site, degree and by the extend of body surface involved
what are files of the dead, moved away or terminated patients called
closed file
what the definition of an EHR
is an electronic record that originates from more than one facility
in a paper record what is not acceptable
obliteration
what is the definition of an EMR
is an electronic record that originates from one facility
advantages of numeric filing
it allows unlimited expansion without periodic shifting of folders and shelves are filled evenly it provides additional confidentiality to the record it saves time in retrieving and filing records quickly
the most frequently used alternatives for data backup
online backup system
period from the last month of pregnancy to the 5 months postpartum
peripartum
what is voice recognition software for transcription is used to dictate what type of report
progressnote, letter,email any type of documents in the healthcare facility
which of the following ICD-10-CM section records additional diagnosis
section III
capabilities of the EHR
specialty software appointment scheduler appointment reminder and confirmation prescription writer medical billing system charge capture ie stores billing codes to help maximize profits and alerts for mistake eligibility verification referral management laboratory order integration patients portal
what information is recorded when interviewing a patient
subjective
which of the following instructions in the alphabetic index indicate that another main term may be reference
the see also note
the second most common place to find diagnosis statement is
treatment or progress note
when coding for drug toxicity what refer to conditions when less of a medication than prescribed is taken
underdosing
how long can a medical facility kip a record
until the minor reaches the age of major i.e 18 +3year
advantages of the EHR
1)reduced medical error by keeping prescription, allergies and information organized 2)reduced costs by preventing duplicate text 3)more legible than handwritten document 4)more secure requires password 5)less storage space 6)information can be accessed from multiple locations 7)readily available patients information
ICD-9-cm is made up of
3 volume and volume 1 and 2 are for diagnostic code and 3 is for hospital
list the 5 basic filing steps
conditioning filing releasing index and coding sorting and storing
what does continuity of care means
continuation of care smoothly from one provider to another so the patient received the most benefit and no interruption in care
name the two types of medical records
electronic paper
A code from category Z37 should be included on
every maternal record when a delivery has occurred
nonverbal communication with the patient when using the EHR
eye contact must be maintained allow screen to be viewed so they are part of the process position yourself next to or at an angle to patients to encourage partnership patients deserve to choose most aspects of their healthcare plan never expected quick decision follow up and make note of any wait time patient requests and enter into EHR make sure patients understand all instructions for test procedures or preparation for procedure
things that are considered objective information
vital signs strep test yellow eye bloated stomach
