Electronic Health record Flashcards by ABEGAIL SERMONIA

T OR F

EHR is not the same as that developed in other countries

TRUE

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T OR F
EHR is a major step and has only been successfully
achieved in a few healthcare institutions to date.

TRUE

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We should focus on encouraging them to:

Improve accuracy and quality of data recorded in a health record

Enhance health practitioners’ access to a patient’s health information

Improve the quality care

Improve the efficiency of health record service

Contain healthcare costs

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T OR F

A paperless environment will come

TRUE

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T OR F

If identified problems are not addressed and remedied prior
to introducing an EHR system, merely automating health
record content and procedures may perpetuate deficiencies
and not meet the EHR goals of the institution or the country.

TRUE

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“Current problems identified in healthcare documentation,
as well as ___ and ____ must be
addressed, and ______introduced before
a successful change can be implemented.”

“Current problems identified in healthcare documentation,
as well as privacy and confidentiality issues must be
addressed, and quality control measures introduced before
a successful change can be implemented.”

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T OR F

Although the introduction of a fully electronic health record
system may seem far off in many healthcare institutions or
countries, they are being introduced rapidly in others and
there is no doubt that the future of health information
management lies with automation and the automatic
transmission of information required for patient
management at all levels of healthcare

TRUE

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What are other terms used to refer to EHR

Automated Health Record [Electronic Health Records
Manual for Developing Countries 11 Records (AHR)]

Electronic Medical Record (EMR)

Computer-based Patient Record (CPR)

Electronic Health Record (EHR)

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An electronic record of health-related information on an individual that conforms to nationally recognized
interoperability standards and that can be created,
managed, and consulted by authorized clinicians and staff across more than one health care organization.

A. AHR
B. EMR
C. CPR
D. EHR

D. EHR

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A. AHR
B. EMR
C. CPR
D. EHR
E. PHR

D. EHR

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Used to describe a collection of computer-stored images of
traditional health record documents

A. AHR
B. EMR
C. CPR
D. EHR
E. PHR

A. AHR

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An electronic record of health-related information on an
individual that can be created, gathered, managed, and
consulted by authorized clinicians and staff in one
healthcare organization

A. AHR
B. EMR
C. CPR
D. EHR
E. PHR

B. EMR

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Used to describe automated systems based on a document
imaging or systems which have been developed within a
medical practice or community health care.

A. AHR
B. EMR
C. CPR
D. EHR
E. PHR

B. EMR

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Most of the focus in the early 1990s was on document
scanning onto optical disks. This addressed access, space,
and control problems related to paper-based records but did
not address data input/output at patient care level.

A. AHR
B. EMR
C. CPR
D. EHR
E. PHR

A. AHR

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More simply stated, this type of a longitudinal electronic
health record could be defined as:
o Containing all personal health information belonging to
an individual
o Entered and accessed electronically by healthcare
providers over the person’s lifetime, and
o Extending beyond acute inpatient situations including
all ambulatory care settings at which the patient
receives care

A. AHR
B. EMR
C. CPR
D. EHR
E. PHR

D. EHR

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Collection of health information for one patient linked by a
patient identifier

A. AHR
B. EMR
C. CPR
D. EHR
E. PHR

C. CPR

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include as little as a single episode of care
for a patient or healthcare information over an extended
period of time

A. AHR
B. EMR
C. CPR
D. EHR
E. PHR

C. CPR

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An electronic record of health-related information on an
individual that conforms to nationally recognized
interoperability standards and that can be drawn from
multiple sources while being managed, shared, and controlled by the individual

A. AHR
B. EMR
C. CPR
D. EHR
E. PHR

E. PHR

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Developed within a medical practice or health center

A. AHR
B. EMR
C. CPR
D. EHR
E. PHR

B. EMR

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Although this form of a computer-based patient record was
implemented in a variety of settings the focus on
exchanging health information was limited to inpatient
facilities.

A. AHR
B. EMR
C. CPR
D. EHR
E. PHR

C. CPR

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• Digital version of paper charts
• Contains medical and treatment history of patients in one
practice or organization
• However, the information of EMRs does not travel easily out
of the practice

EMR

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Focus on the total health of the patient
o Going beyond standard clinical data collected in the
provider’s office or during episodes of care and
inclusive of a broader view on a patient’s care
o Designed to reach out beyond the health organization
that originally collects and compiles the information
oThey are built to share information with other health
care providers and organizations such as laboratories
and specialists

EHR

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are able to electronically collect and store
patient data to supply that information to the providers and
requests, permit clinicians to enter orders directly into the
authorized provider order entry system, and advise
healthcare practitioners in providing decisions to accord to
such as reminders, alerts, and access to the latest
research findings or appropriate evidence based
guidelines.

A. EMR
B. EHR
C. EMR and EHR

C. EMR and EHR

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refers to organizational systems that include at
least the 4 core functions

A. EMR
B. EHR
C. EMR and EHR

A. EMR

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refers to systems that share information across different organizations, perhaps through a regional health information organization A. EMR B. EHR C. EMR and EHR

B. EHR

T OR F The decisions of probabilities with the EMR are more robust than the digital version of the paper medical record.

TRUE

a major issue that should be | addressed before moving forward to automation

Unique patient identification

the backbone of an effective and efficient health record system, whether manual or electronic

Accurate patient identification

Other possible issues

Clinical data entry issues and lack of standard | terminology

a set of common standards for data collection and is used to promote uniformity in documentation, data processing and maintenance

data dictionary

what issue is seen in • Clinical data standards are developed to ensure that data collected in one hospital department or facility means the same in another department or facility

Clinical data entry issues and lack of standard terminology Resistance to computer technology and lack of computer literacy Strong resistance to change by many healthcare providers High cost of computers and computer systems and funding limitations Concern by providers as to whether information will be available on request Concerns about privacy, confidentiality, and the quality and accuracy of electronically generated information Quality of electronic healthcare information and accuracy of data entries Lack of staff with adequate knowledge of disease classification systems Manpower issues – lack of staff with adequate skills Environmental Issues Involvement of clinicians and hospital administrators

T OR F The lack of standard terminology could be a major stumbling block to the successful introduction of an electronic health record system

TRUE

T OR F Successful implementation of an EHR will be dependent on the computer skills of all healthcare professionals and other staff. Although in today’s world many use computers, particularly the Internet, some are still not proficient in using computers as they do not routinely use computers at work or at home.

TRUE

the main strategy to have in place | to help overcome such resistance ARE (3)

to have them involved from the outset in discussions on the development and implementation of an EHR As well as being trained in the technology they need to be involved in system selection and design.

Need to compare the current system costs plus | perceived costs for the new EHR system addresses what issue?

High cost of computer systems and funding limitation

T OR F In EHR the information will not only be readily available at all times

TRUE * Information should always be readily available * Information can be accessed more efficiently Providers need to be assured that while the information will not only be readily available at all times, they will be able to access it more efficiently In fact, the information will and should be more readily available than in a manual system where medical records are filed in an MRD which is not open 24-hours a day.

T OR F In EHR the information will and should be more readily available than in a manual system where medical records are filed in an MRD which is not open 24-hours a day.

TRUE

The relevant legal issues should include _________ from electronic media on which it is stored. The durability of the electronic media must also be tested and documented.

retention | schedules and how information is to be retrieved from

T OR F it is suggested that the quality of electronically recorded data is better as there are measures in place, such as edit checking, aimed at ensuring accuracy

TRUE

The characteristics of data quality include: (6)

Accuracy and validity of the original source data Reliability Completeness Legibility Currency and Timeliness Accessibility

T OR F All these characteristics are important in manual record systems

FALSE All these characteristics are important in both manual and electronic record systems Whatever the system, the quality of healthcare data is crucial, not only for patient care, but also for monitoring the healthcare services and the performance of the institution

coding training programs is extremely limited is under what issue

Lack of staff with adequate knowledge in disease classification systems

T OR F Currently, there is more computer-assisted coding than coding entirely by computer

TRUE

staff may be available but their skills may not be adequate for the tasks expected of them is under what issue

Manpower issues -- Lack of staff with adequate skills

A major concern in many developing countries is an available and reliable electrical wiring and supply of electricity within the healthcare facility is under what issue

Environmental issue

T OR F Another important environmental issue is the amount and quality of available space needed for computers and other equipment.

true

could be the most difficult of the non-technical issues to be addressed.

Willingness by healthcare providers to collaborate and | share data with other providers and also with the patient

Their specifications and input are important for their acceptance of the system, especially issues relating to ownership of the information is under what issue

Involvement of clinicians and hospital administrators

must be in place to ensure against loss, destruction, tampering and unauthorized use of electronic records.

safeguards

SAFEGUARDS means for ongoing monitoring and evaluation of the system to ensure that all users adhere to the stated standards A. Efficient back-up system available B. Contingency plan C. Securing workstations and password requirement D. Access control to authorized persons only E. Audit control F. Administrative security requirements G. Incident reporting and response mechanisms H. Policies and procedures and workforce training

G. Incident reporting and response mechanisms

ensure that uses and disclosures are made only as permitted or required by law A. Efficient back-up system available B. Contingency plan C. Securing workstations and password requirement D. Access control to authorized persons only E. Audit control F. Administrative security requirements G. Incident reporting and response mechanisms H. Policies and procedures and workforce training

H. Policies and procedures and workforce training

for disaster recovery need to be in place in the case of an electrical breakdown or other emergency A. Efficient back-up system available B. Contingency plan C. Securing workstations and password requirement D. Access control to authorized persons only E. Audit control F. Administrative security requirements G. Incident reporting and response mechanisms H. Policies and procedures and workforce training

B. Contingency plan

where access may be monitored to ensure only authorized persons use the system and to identify when changes are made in the record A. Efficient back-up system available B. Contingency plan C. Securing workstations and password requirement D. Access control to authorized persons only E. Audit control F. Administrative security requirements G. Incident reporting and response mechanisms H. Policies and procedures and workforce training

E. Audit control

for all users. The passwords should be changed regularly to maintain security A. Efficient back-up system available B. Contingency plan C. Securing workstations and password requirement D. Access control to authorized persons only E. Audit control F. Administrative security requirements G. Incident reporting and response mechanisms H. Policies and procedures and workforce training

C. Securing workstations and password requirement

ensure health records are available when needed for patient care and other official purposes but may not be accessed by unauthorized persons A. Efficient back-up system available B. Contingency plan C. Securing workstations and password requirement D. Access control to authorized persons only E. Audit control F. Administrative security requirements G. Incident reporting and response mechanisms H. Policies and procedures and workforce training

D. Access control to authorized persons only

for risk analysis processes and for management must also be in place A. Efficient back-up system available B. Contingency plan C. Securing workstations and password requirement D. Access control to authorized persons only E. Audit control F. Administrative security requirements G. Incident reporting and response mechanisms H. Policies and procedures and workforce training

F. Administrative security requirements

designated to perform clearance checks on members of the workforce who will have regular access to the system

information security officer

T OR F it may be possible to implement a welldesigned EHR, but if potential issues and challenges have not been addressed, and if users have not been involved in the design or in the selection of the system, are not properly trained, and/or are not supported by the healthcare authorities, the system may not be used effectively and may therefore fail to produce the anticipated outcome

TRUE

will provide immediate access to data and enable processing that data in a variety of ways to support both the decision making process by health professionals for patient care and clinical and health services research

EHR

The proposed electronic health record will cover the | following:

All personal health information about an individual, entered electronically by healthcare providers at the point of care over a person’s lifetime Accessibility by healthcare providers and departments within the hospital from which the patient has received care Organization of information primarily to support continuing, efficient and quality healthcare within the healthcare facility

BENEFITS OF THE USE OF EHR TECHNOLOGY (5)

1. Improve healthcare quality, safety, and efficiency and reduce health disparities 2. Engage patients and families in their health care 3. Improve care coordination 4. Improve population and public health 5. Ensure adequate privacy and security of personal health information

Secure website through which patients can electronically | access their medical records

PATIENT PORTAL

Patient portal enables users to

o Complete forms online o Schedule appointments o Communicate with provider o Request refills on prescriptions o Review test results o Pay bills

fully functional EHRs | provide

order entry capabilities beyond ordering | medications and decision support capabilities

FACTORS THAT INCREASE EHR ADOPTION

``` o Improve patient safety o Reduce medical errors o Reduce duplicate services o Improve organizational efficiency o Optimize reimbursement o Complete locally and regionally ```

Barriers to Adoption

1. Financial Barriers 2. Organizational or Behavioral Barriers 3. Technical Barriers

T OR F EHR may not be the same as those in the developed countries

TRUE

a type of patient record is maintained by the individual to track personal healthcare information

Personal health record (PHR)

T OR F | PHR is not the same as [other] health records

TRUE PHR is not the same as [other] health records because it is not managed by a healthcare organization or provider

T OR F PHR constitutes a legal document of care but contains all pertinent health care information contained in an individual’s health record

FALSE Does not constitute a legal document of care but contains all pertinent health care information contained in an individual’s health record

effective tool enabling patients to | be active members of their own health care teams

PHR

t or f patient records may contain some or all of the documentation listed

TRUE

a repository for a variety of healthcare data and information which is captured by many different individuals involved in the care of the patient

Patient record

Information found in the identification screen of a health or medical record originates at

at the time of registration or | admission of our patient

INCLUDES o Patient’s name, address, and telephone number o Insurance carrier (most likely needed, personal information has a great impact for insurance companies) o Policy number o Diagnoses and disposition at discharge

Identification screen

TRUE OR FALSE Problem list is used as clinical and administrative document

FALSE Identification screen is used as clinical and administrative document

T OR FALSE | Identification Screen is not only used for patient management, but also reimbursement or possible insurance claims

TRUE

• Includes diagnosis and health condition of patient • Frequently contains a comprehensive problem list which identifies significant illness and operations the patient has experienced

Problem list

T OR F Problem list is Generally maintained over time By attending or primary care physician, or health care providers involved in patient care o Not specific to a single episode of care (naeedit or nadagdagan over time)

TRUE

Who is responsible in documenting and maintaining information in medical records?

Nursing personnel

* Lists medicines prescribed and subsequently administered | * List medication allergies experienced by the patient

Medical records / Medical Administration record

Medical record is also known as the

Medical Administration Record

``` This component describes: o Any major illnesses and surgeries the patient had o Family history of disease o Patient health habits o Current medications ```

History

Documented by physician or other care provider at the beginning of or immediately prior to an encounter or treatment episode

History

This component of the report states: o What the physician found after the hands-on patient examination

Physical

o Documents that will provide the initial assessment of the patient for the particular care episode o Provide basis for diagnosis and subsequent treatment o Provide a framework in which physicians and other care providers can document significant findings o Important and created initially during the first encounter with the patient

History and Physical

T OR F initial history and physical observations is a one-time activity

TRUE

Results of reassessments are generally recorded here

progress notes

Should reflect patient’s response to treatment along with | observations and plans for continued treatment

progress notes

T OR F | The patient is responsible for the content of progress notes

FALSE Each provider is responsible for the content of his/her notes

FORMAT OF PROGRESS NOTES

``` SOAP FORMAT o Subjective findings o Objective findings o Assessment o Plan ```

• Records opinions about the patient’s condition • Made by another health care provider at the request of the attending physician

Consultation note or report

``` • Directions, instructions, or prescriptions • Given to other members of the health care team regarding the patient’s: o Medications o Tests – laboratory, radiologic o Diets o Treatments o Rehabilitation, etc ```

Physician's order

Interpret images produced by x-rays, mammograms, ultrasounds, scans, and other medical imaging machines

Radiologist

T OR F Imaging and X-ray reports and images are typically not considered part of the legal patient record per se

TRUE

Contain results coming from a clinical laboratory or | anatomic pathology laboratory

LABORATORY REPORTS

``` a legal document o Admission o Treatment o Surgery o Release of information o Or anything that will be performed or done to the patient NEEDS ```

Consent and authorization forms

* Describes any surgery performed | * Lists the names of surgeons and assistants

Operative Report

Responsible for the information found in operative report

Surgeon

* Describes tissue removed during any surgical procedure | * Diagnosis based on examination of the tissue

Pathology report

Responsible for the information found in pathology report

pathologist

``` Summarizes the hospital stay including: o Reason for admission o Significant findings from tests o Procedures performed o Therapies provided o Responses to treatments o Condition at discharge o Instructions for medications, activity, diet and follow-up care ```

Discharge summary

T OR F Each acute care patient record contains a discharge summary

TRUE

Responsible for information in discharge summary

Attending physician

Electronic Health record Flashcards

(104 cards)