Storage and Retention Flashcards
(21 cards)
who is initiating computerized medical record keeping?
The Provincial and Federal government
what is the ultimate end result?
one record–one patient
what are the advantages of electronic medical record keeping?
- freed up space
- time consuming to covert existing paper records to electronic records.
- frustrating glitches
how is the electronic medical record(EMR) used in the examining room?
- discussion of up-to-date lab results, consultations, and tests.
- Dr.’s document health info using open text or fully structured EMR.
- patients can sign the computer screen making for a true “paperless” office.
Provide examples of EMR components the physician would complete during a physical exam.
flow sheet past medical history medication profile problem list allergy alert lab/diagnostic test
List the electronic safeguards that EMR systems in Alberta must have
- only authorized personnel can access the EMR
- each user is assigned a unique identifier in EMR
- different access levels
- the EMR is password protected.
- audit trail in place.
- electronic signature can be authenticated.
What are the two ways that clinical records are classified when entering data into the EMR?
- open text, information is entered on a “ blank page”.
- can use templates such as SOAP
- fully structured (fill in blanks)
- information is entered into defined fields.
What is a tickler file?
-a reminder system
traditional-file folders, binder ( color coding, should be visible, checking becomes routine)
Computerized - pop up messages
What is archiving?
-taking a file from active use and storing it in a secondary location or “medium”
Define active, inactive, and closed files.
Active: still in use.
Inactive: patient not seen for a predesignated period of time/not sure if patient has left practice.
Closed: clients leave the practice or die.
When are inactive and closed files stored and for how long?
- Can be stored off location.
- in Alberta, a period of 10 years from dat e of separation from hospital or 2 years past the date of majority, which ever is longer.
How are archived paper records filed?
- files have to be able to be retrieved quickly.
- can be organized by year or range of years.
- may use same filing systems as active charts.
How are electronic charts archived? Do electronic charts need to be archived?
YES!
-usually moved to another medium.
Name and explain four archiving option
- microfilm
- microfiche
- CD Rom- electronic generated information
- Magnetic tage - temporary storage medium for computer generated information( scanned from paper. Often used for backing up computer information.
What is a centralized system of storage?
- used in private practice.
- in hospitals - Health records department.
- all records - inpatient & outpatient kept in one file, one location.
- often purged (centralized records)
What is a decentralized system of storage?
- parts of patient records reside outside central area.
- hospitals have clinics that store charts separately (diabetes/cast clinics)
- some records kept separate due to sensitive nature (abortion clinic/AIDS)
Why would files be somewhere other than the centralized or de-centralized filing systems?
- pulled for reference.
- review
- waiting for lab results or letter to add to chart.
- dictation
- billing
The Provincial and Federal government are the ones who are..
initiating computerized medical record keeping
one record–one patient
is the ultimate end result and initialized plan
- freed up space
- time consuming to covert existing paper records to electronic records.
- frustrating glitches
are the advantages of electronic medical record keeping
- discussion of up-to-date lab results, consultations, and tests.
- Dr.’s document health information using open text or fully structured EMR.
- patients can sign the computer screen making for a true “paperless” office.
Is how the electronic medical record (EMR) used in the examining room.
