Medical Records

What does the Medical Record contain?

All of a patient’s medical history related to a provider. It includes charts, notes, information to identify the patient and support the diagnosis, reason for appointment, and past and present illnesses and treatments.

What is important to know about a medical record?

Every aspect of a patient’s treatment is documented in this record

What are the most common parts in a medical record?

Questionnaire, registration/admission, consent for treatment, patient history, plan of treatment, and progress report forms

What does the questionnaire contain?

Asks about the patient’s medical history, insurance coverage, and other important facts

What is Sexual Orientation?

A person’s pattern of emotional, romantic, and sexual attraction to people of a particular gender

What is Gender Identity?

A person’s inner sense of where they belong on a continuum of masculine to androgynous to feminine traits

What are the two things that knowledge upon SOGI allow for?

It reduces health disparities among sexual and gender minority populations and it helps identify appropriate preventive screenings for patients

What is in a registration/admission form?

Name, address, and insurance information

What are the good recording practices?

Legible, understandable, timely, error free, and reproducible

What is an addendum?

An addition of information that was left out of the original entry

What does the joint commission accreditation require?

A doctor writes a discharge summary

How do you correct a written medical record?

Cross entry out with a single line. Correction should be noted as well as the reason for the error. Initials of the person making the correction should be noted, including the date and time the error was discovered.

What should a provider do if information must be added to the medical record?

Professionals can make arrangements for providers to add it within 15 days of the patient’s discharge

What kind of records were used in the past?

Paper charts. There have been word-processing systems since 1980, but then they would be printed and placed in the paper chart.

What is the definition of the Electronic Health Record?

A longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting

What does the EHR assist healthcare providers with?

Decision-making, preventing medical errors, and enhancing medical research

What is the goal of the Electronic Health Record?

To make all medical records universally portable, provide continuous care, and support administrative functions

When did the first electronic records appear?

The mid-1960s. It became necessary for accounting. The government instituted medicare in 1965.

What happened in the next two decades after the electronic record was created?

Information was mostly numerical and inherently structured

What is discrete data?

Information that consists of separate and limited values. It’s also known as quantifiable data (data that can be determined, indicated, or expressed)

What are examples of discrete data?

Age, height, and weight

What are not examples of discrete data?

Clinical information (what, where, why)

What was the only type of data computerized healthcare systems could capture?

Discrete data (information stored into consistent categories, including billing, lab results, pharmacy records, and radiology records)

What was the major drawback of original computer health records?

They were specific to single institutions which meant healthcare providers couldn’t easily share ER data

What makes up most of the information in a medical record?

Discrete data

What happened in 1990?

The EHR took on a new purpose: Patient’s needs should play a role too

What happened in 1991?

The Institute of Medicine created a report: The computer-based patient record: an essential technology for healthcare. It emphasized that the patient is the primary beneficiary of the computerized record.

What did the US department of defense do?

They created a clinical care patient record system called the composite health care system (CHCS) which is used worldwide

What did the veterans administration do?

They created the decentralized hospital computer program (DHCP) for medical care of veterans nationwide. It linked a broad network of healthcare providers in different facilities.

What happened in 2003?

The IOM released another report outlining what the EHR should be and the capacities it should have

What happened in 2010?

The US government renewed a national commitment to the EHR to replace all paper records with computer-based systems. Financial incentives were given to healthcare entities who transitioned to the EHR.

What happened from 2015 to 2018?

Medical payments were adjusted for providers who were not meaningful users of EHR technology

What is the HIE? What does it do?

Health Information Exchange. It allows healthcare professionals and patients to appropriately access and securely share a patient’s medical information electronically.

What is the IOM’s definition of CPR?

The computer-based patient record is an electronic patient record that resides in a system specifically designed to support users by providing accessibility to complete and accurate data

What are the 8 things the EHR/CPR should be capable of?

Health info/data, result management, order management, decision support, electronic communication/connectivity, patient support, administrative processes, and reporting/population health management

What is the CPOE and what does it do?

The Computerized Provider Order Entry. It allows clinicians to directly order things and transmit them directly to the recipient, resulting in less medical errors.