advantages of the EHR

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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


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