EHR & Managing Medical Records

What are the benefits of electronic health records?

eliminates duplication of forms and simplifies reviewing information

How do electronic health records decrease medical errors?

decreases lost or misfiled paper records, mishandled patient messages, inaccurate/ineligible documents. mislabeled lab orders. unreadable prescription orders

What are the five basic steps for filing?

- Conditioning

- Releasing

- Indexing and Coding

- Sorting

- Sorting and Filing

What is done during conditioning?

grouing related papers together, removing paper clips and staples, fixing damaged records

What is done during releasing?

marking form to be filed with provider's initials and stamp

What is done during indexing and coding?

determining where to place the file in the record

What is done during sorting?

ordering papers in a filing structure; placing them in specific groups

What is done during sorting and filing?

securing documents permanently in the file

What are the three basic steps for filing?

alphabetic, numeric, and subject

What is alphabetic filing?

most widely used; last name, first name, middle initial

What is numeric filing?

typically combined with color coding and in larger health centers, this method allows for unlimited expansion

What is subject filing?

used for general correspondence; all correspondence placed under specific subject and tab

What is an electronic medical record (EMR)?

digital charts to be used within a facility

What is an electronic health record (EHR)?

digital version of a patient's paper chart; includes EMR and other info to be used between facilities

What is a personal health record (PHR)?

patient records of their own medical data and health history; data and access controlled & owned by patient; secure internet sites

What are the legal requirements related to the maintenance and storage of files?

- should never leave office

- processed in timely manner

- locked away at closing

How long should Medicare and Medicaid patient records be kept for?

10 years

How should medical records be destroyed?

shredded by professional and confidential document destruction service; keep detailed record of when, how, and who destroyed it

How do personal health records differ from electronic health records?

- are not legal documents

- not entered by healthcare professionals

- cannot be disclosed without patient's written permission

- contain treatment information related to patient from all providers

How do electronic medical records differ from electronic health records?

EMRs are from one provider only and are not shared or moved outside healthcare setting, used primarily for diagnosis and treatment; EHRs are designed to be shared and support medical decision-making

What are advantages of EHR programs?

- fewer lost medical records

- increased readability/legibility

- ease of access for multiple users

- decreased duplication

- eliminated transcription costs

When correcting an EHR, what should you do?

use a new entry (addendum) for corrections

What is part of social history?

tobacco use, alcohol use, drug use, marital status, occupation

What is the Review of Systems (ROS)?

Systematic questions about each body system

When should the Review of Systems be completed?

at check-in

The full review of an ROS is completed by

physician

What is the chief complaint?

reason for visit; history of present illness (HPI)

What are questions you can ask a patient regarding pain provoking factors?

What makes it worse, what makes it better?

What are questions you can ask a patient regarding pain quality?

what does it feel like, have you ever experienced it before?

What are questions you can ask a patient regarding pain region/radiation?

where is the pain, is it in one spot, does it travel?

What are questions you can ask a patient regarding pain severity?

is this the worst pain experienced, is it worsened with movement? pain scale

What are questions you can ask a patient regarding pain time?

when did it start? how long has it persisted and lasted? has it ever happened before?

What are questions you can ask a patient regarding pain treatment?

has the patient been given any medication to treat it? what time was the last dose? has the patient tried home remedies? what has/has not worked for the patient?

What is Meaningful Use?

guidelines imposed due to the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009 to improve quality, safety, efficiency, and reduce health disparities

What does Meaningful Use strive for?

better patient outcomes

What are the basic components of Meaningful Use?

use of certified EHRs should be used meaningfully to exchange health information and improve healthcare quality, helps submit clinical quality, etc

What is the MA's responsibility when it comes to Meaningful Use?

update patient record each time patient is seen; smoking status, medication list, vital signs

What is the Release of Information Form (ROI)?

aka HIPAA form; allows practice to share patient info

What is the consent to treat form?

legal guardian/parent gives physician permission to treat child

Who can authorize forms?

patient, minor's parent/legal guardian, or power of attorney (POA)