Chapter 1 & 2 Electronic Health Records

Chief Complaint (CC)
The patient’s stated primary reason for seeking treatment.
Clinical decision support (CDS)
A set of patient-centered tools embedded within EHR software that can be used to improve patient safety, ensure that care conforms to published protocol for specific conditions, and reduced duplicate or unnecessary care and its associated costs.
CMS 1500 claim form
A standardized template that speeds claims processing for doctors and suppliers; also called a universal claim form.
The sum of money that is paid by the patient, usually at the time medical services are rendered.
Day sheet
A register for daily business transaction; also called a day journal
Electronic Health Record (EHR)
A computerized patient health record that allows the electronic management of a patient’s health information by multiple healthcare providers and stores the patient’s contact information, legal documents, demographics data, and administrative information, the term can also refer more broadly to a system that manages such records.
Electronic transcription
Data entry using handwriting or voice recognition or other digital means.
The ability of separate EHR systems tow share information in compatible forms.
Patient information form
A form used to gather data about the patient, including contact information, health history, current health status, and chief complaint.
Patient statement
Document that contains the amount owed and other billing details.
Practice management software
Software used in a medical office to accomplish administrative (nonclinical) tasks, including entry of patient demographics, record keeping for insurance and other billing transactions, appointment scheduling, and advanced accounting functions.
Programs and other operating information inside the computer.
Practice Partner
A top–rates CCHIT-certified, integrated system of EHR and practice management software published by McKesson Corp. Practice Partner is used with this textbook to illustrate the features and functionally of an EHR system.
Third-party payer
A party other than the patient, spouse, parent, or guardian who is responsible for paying all or part of the patient’s medical costs.
Active Patient
An established patient has seen the provider within the last 3 years.
Closed Patient Record
The record of a patient who has not been seen by the provider in 3 or more years.
Personal digital assistants (PDAs)
A small handheld personal computer used by healthcare personnel to document clinical findings, look up information at the point of care, and send and receive emails. among other functions.
To reload the page or update it with current data.
The length of time records are stored (retained) by a medical office; requirements vary from state to state.
Status Code
Codes that indicate a patient’s behavior or current status, such as “LA” for “late arrival”.
What is a medical record?
A physical collection of an individual’s healthcare information.
What are the benefits of having medical records?
Who can document in a patient’s chart?
Documenter, Doctor, Medical Assistant, Nurse Practitioner, Physical or occupational therapist, Surgeon, Medical Biller, etc.
Who owns the patient chart and why?
Patient medical records are considered the property of the individuals who created it.
What are the patients’ rights to their medical records?
The patient has legal rights to access or copy their own medical information at any time by signing a medical release form; however the original copy of the medical record never leaves the facility that owns it. A medical practice may legally assign a fee for copying a medical record. There is one exception to the patients right to view his or her medical records which is the doctrine of professional discretion. The principle states that doctors can exercise their best judgement when deciding whether or not to share progress notes and clinical observations with a patient who is being treated for mental or emotional disturbances.
Briefly describe the core functions of the EHR system.
-Health Information and date [management]: central repository for the patient’s health information from a variety of sources.
-Result management:Instituting an EHR system should make test results easily accessible.
-Order management: The ability to order tests and prescribe medications electronically reduces errors and lower costs.
-Decision support: The EHR software should offer features that help clinicians manage patient care according to evidence-based treatment guideline.
-Electronic communication and connectivity: Chief advantage; allows all providers and institutions involved in a patient’s care to communicate and share data efficiently, thereby improving the quality of the patient’s care
-Patient support: Tools for patient education; such as wound care instructions
-Administrative processes:Billing and scheduling can be handled electronically
-Reporting and population health: Diagnoses of infectious diseases can be reported confidentially to public health authorities, and researchers can access EHR databases to gather epidemiologic statistics.
What are the advantages of electronic health records?
Improved Quality and Continuity of Care, Increases Efficiency, Improved Documentation, Easier Accessibility at the Point of Care, Better Security, Reduced Expenses, Improved Job Satisfaction, Improved Patient Satisfaction
What are the disadvantages of electronic health records?
Lack of Interoperability, Cost, Employee Resistance, Regimentation, Security Gaps
Briefly describe the advantages of having clinical decision support tools.
Generate patient data reports and summaries, Ensure that the patient’s care complies with established screening recommendations for the diseases for which he or she is at risk, Plan treatment in accordance with evidence-based treatment guidelines, Complete documentation templates specific to the patient’s diagnoses , etc.
How are the EHR protected during natural disasters?
They are backed up by a secure, web-based system and thus can be retrieved even when computers are destroyed.
Why is it important to properly document in the patients record?
To avoid delay of reimbursement or denial of claims because of medical necessity of services has not been proved, Tom comply with insurance companies’ enforcement of documentation guidelines for healthcare facilities, To protect the practice in case a malpractice suit is brought.
What are the duties of an AMA when it come to EHR?
Reception, Appointment scheduling, electronic chart creation, Inactive chart purging, gather and entering patient information, maintaining email communications etc.
What are the duties of a billing and coding professional when it comes to EHR?
Creation of billing statements, Assignment of procedural and diagnostic codes, Linking procedure and diagnostic codes for reimbursement, Auditing, Filing patient billing statements.

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