Health information and data provides a defined data set that includes such items as medical and nursing diagnoses, a medication list, allergies, demographics, clinical narratives, and laboratory test results.
Health information and date improve workflow processes by eliminating lost orders and ambiguities caused b y illegible handwriting, generatging related orders automatically, monitoring for duplicate orders, and reducing the time required to fill orders
Health information and data includes systems that deliver prompts regarding preventive practices, information about prescriptions, and clinical data regarding disease diagnoses and management
Health information and data reduces lag time between regonition and treatment of medical problems and it lends itself to electronic consults between physicians.
Health Insurance Portability and Accountability Act
Institute of Medicine
Computer-based Patient Record Institute
Health Information Technology for Economic and Clinical Health Act
Any information that relates to the past, present, or future physical condition of a person that is stored in an electronic format
The portions of a patient's medical records that are stored in a computer system as well as the functional benefits derived from having an electronic health record
Patient information that is stored electronically and may be accessed by both the patient and the patient's healthcare provider on demand
Any healthcare information that is stored by computer
Fostering regional collaborations
Ecouring use of PHR
Accelerating research and dissemenation of evidence
Promoting EHR diffusion in rural and underserved areas
Because it makes funding available to help you implement a certified EHR in your practice
Because it will reduce your Medicare payments by five percent if you continue to use paper charts in 2015
Because it offers you financial incentives for implementing an EHR before 2015
Because is requires you to offer telemedicine to your patients by 2020
Connectivity between multiple care providers
Management of administrative processess and reporting
Statistical collection and reporting related to population health
Provide decision support
A summary of the patient's symptoms
A record of the patient's vital signs
The main rason a patient seeks care
The doctor's assessment of what is wrong with the patient
They may be either paper or electronic because EHR systems require a handwritten prescription for the patient file
They are electronic records but the software does not support electronic prescription submission
They are paper records because electronic records require electronic submission of prescriptions
They may be either paper or electronic buy your doctor simply prefers to write out her prescriptions
It only contains information related to the patient's current day
Its central element is the physician's exam note
It inclues more information than an outpatient chart
It includes nurses's notes that indicate the patient's response to treatment
It incorporates computer systems from many different vendors
It stores patient data in a single electronic medical record
It mnust be accessible to any specialists who are also treating the patient
It requires clinicians to use an interface to view data from different systems
A nurse enters a patient's vital signs into the patient's record at the end of his shift
A transcriptionist types an encounter note and sends it to the physicians
The physician prints the encounter note at the conclusion of the patient's visit
A nurse practioner creates an exam note from memory while the patient gets dressed.
Is easy to drop
Runs on batteries
Is harder of IT departments to update
Lacks a keyboard
Data capture at the point of care
Electronic communication and connectivity
Provison of decision support
Patient support
It saves time and money by eliminating the cost of dictation and transcription
It allows a clinician to sigan an encounter note before the patient leaves the office
It ensures that all infromation required for referralis available immediately
It gives the patient a chance to make corrections to his medical record
Any clinician who works directly with patients when providing care and is therefore bound by HIPAA mandates
Anyone who has been granted access to protected health information in electronic form
A credentialed healthcare professional who is in good standing with a medical board and qualified to practice in a state
A healthcare provider who is considered entitled to recieve incentive payments under the HITECH Act.
CPOE
Drug-formulary checks
Maintain active medication list
Record smoking satus for patients 13 years or older
ONC-ATCB
CPRI
CHCS II
AHIMA
The idea for electronic health records first originated with the Health Insurance and Accountability Act
The Computer-based Patient Record Institute outlined eight core functions that any EHR should be able to perform
It has primarily been physicians who have led the charge in the impetus behind developing a nation EHR system
The HITECH Act signed by President Obama is promoting the widespread adoption of electronic health records
AHIMA
Leapfrog Group
Kaiser Permanente
Agency for Healthcare Research and Quality
The workflow process begins when the patient request an appointment
The physician dictates her exam notes at the conclusion of the patient encounter
The patient discusses his symptoms with his physican during the exam
The patient leaves his physician's office with a printed copy of the encounter
Trend analysis
Health maintenance
Discrete data
Alerts
Fielded data
Coded data
Transcribed exam notes
Annotated drawings
A person is needed to interpret its meaning
It must first be imported from outside text files
It requires little storage space
It is only useful if it is codified
Decision support
Trend analysis
Research
Diagnosis
White male
20120331
Gall bladder
Normal urine protein
Body Structure
Symptoms
Physical Examination
Therapy
Laboratory test results
Biomedical information
Nursing diagnoses
Point-of-care documentation
The image has been successfully cataloged
You need to use OCR software to catalog this image
You need to complete the cataloging process by adding the patient's name
You need to enter identifying data about the document into the computer
It imports digital images into the EHR system
It associates images with the patient EHR record
It is seperate from the EHR system
It is used to archive diagnostic images
Scan all of the printed pages into the new system
Keep the paper charts, but begin entering all new information electronically
Import the word processing files from any transcribed dictation as text records
Hire transcriptionist to retype all of the old information into the EHR
A medical assistant scans and catalogs a copy of a patient's test results
A clinician selects a protocol through a patient chart at the point-of-care
A radiology technician links to a copy of an X-ray stored in a PAC
A medical tanscriptionist types exam notes using a word processor
The text data is searcable by computer
The text data may be incorporated into the EHR system
The text document will dynamically resize itself when viewed on a handheld device
The text data is codified by the EHR once it has been imported
DICOM
HL7
PAC
IMH
DICOM
HL7
PAC
IMH
An article on from a professional medical journal
A generic equivalent to a brand name drug
A graph showing a patient's cholesterol levels over time
A message automatically generated from the data
The patient is an authority on the symptoms he experiened when an illness started
The patient can enter accurate information about her social and flamily history
The patient can review and make corrections to previous entries made by medical staff
The patient can comment on the success of previous treatments that were recommended by the physician.
ABN alert
Formulary alert
Nonaction alert
Electronic lab order system alert
DUR
PDR
ABN
HL7
Trend analysis
Health maintenanace
Alerts
Decision support
Treatment recommendations for the use of certain drugs
A standard plan of therapy established for different conditions
Evidence-based guidelines used for patinet diagnoses
Medication dosing guidelines based on test results
Patient's symptoms
Physician's observations
Service that was rendered
Treatment plan
It must be kept secret
It creates a permanent record of your use of the software
It is unique to you
It serves as your electronic signature
Encounter View Pane
Medcin Nomenclature Pane
Menu Bar
Entry Details
Options
Graph
Encounter
Enter
Entry Details
Note View
Sx tab
Outline View
Creating a new encounter
Selecting a patient
Assigning a finding
Verifying patient information
Subjective
Objective
Assessment
Plan
This symptom is not the right match for the patient
Facial twitching is the main title for a new subcategory
The tree for this finding has been collapsed
This is the most specific finding available for the symptom
Typing his patient identification number
Typing the patient's first name and last name
Scrolling through the list of paitent names
Type the patient's last name, followed by R.
To document clinical notes in a codified electronic medical record
To allow physicians to write prescriptions electronically
To perform drug utilization reviews and send alerts
To provide both patients and healthcare providers equal access to information
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