Patient Care Coordination

Medical Record Formats

the way a medical recorde is organized is known as its format; two types of medical record formats are the source-oriented record and the problem-oriented record (POR)

Source-oriented records

used in most offices in the medical office for organizing a paper-based patient record; the documents in a source-oriented record are organized into sections based on the department, facility, or other source that generated the information

Problem-oriented medical record

are organized according to the patient's health problems, developed in 4 stages: establishing a database, compiling a problem list, devising a plan of action for each problem, following each problem with progress notes

Chronological Filing

system is based on dates; units are year, month, and day; most current date is filed first; most commonly used to file documents in a patient's chart

Reverse chronological order

the most recent document is placede on top or in front of the otherts, thus the oldest documents are on the bottom or at the end of that section

Alphabetic Filing

file the patient chart according to the spelling of the last name; if two or more patients have the same last name, then use the first name next followed by using the middle name

Numeric Filing

patients are assigned a number as they begin using the practice and their files are labeled as such; new patients are assigned the next number in order

Authentication

allows the healthcare worker to use the computer network with a password and a log in

Levels of Authorization

allow a computer network to have specific levels of authorization so that certain screens and certain functions are available onlyu to users with the correct level of authentication

Automatic logoff

all users should log out of the computer network when leaving the workstation; if the user forgets to log out, the software has a feature that automatically logs a user off after a predetermined amount of time

Firewall

a system that protects a computer network from unauthorized access from users on its own network or another network on the internet

Encryption

refers to a process by which electronic information is changed into an unreadable form that requires ther original encryption software to reverse the process

HITECH

The Health Information Technology for Economic and Clinical Health Act; increases the security provisions of HIPAA and adds increased financial penalties for privacy violation; requires notifications of patients for unauthorized use and unencrypted disclosure is PHI (patient health information); breaches involving more than 500 patients must be reported to federal agencies and sometimes local media