EHR
used to record, pt history, chief complaint, vital signs, allergies, pt. education, medication lists, and test results
Documentation
Makes diagnosis and treatment more efficient
Promotes patient safety and reduces medical errors
Serves as a risk management function by providing evidence of communication
Allows related items, such as health history, progress notes, patient letters, and
A higher standard of care
What does EHR documentation help the provider achieve?
Speech Recognition
a technology that converts speech into text, as a provider speaks into a microphone
Eliminating the need for filing or transcription
Allows the user to work hands-free
Eliminates the problem of misplaced or misfiled patient notes
Decreases the rate of transcription mistakes
Lowers the cost of transcription
Reduces the amount of time necessary to complete documentation
Increases the ove
Advantages of Speech Recognition
Med refills, sick calls, patient treatment questions
Examples of telephone documentation
E-Visit
also termed web visit
or online consultation
evaluation and management service provided by a physician or other qualified health professional to an established patient using a web based or similar electronic based communication network for a single patien
E-Visits Guidelines
Web visit or online consultation
Monitoring chronic disease
Not for new patients
HIPAA-compliant online connection
Visit must be documented
Define time period for e-visit
encounter
in SimChart for the Medical Office the pt visit
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allows the user to document all clinical documentation for the pt. visit
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Comprehensive Visit
Office Visit
Phone Consultation
3 types of encounters
Environmental
Seasonal
Contact
Food
4 types of Allergies
Allergies
Verify at every visit- before med is administered or other treatment is given, before any medical procedures are performed
Document corresponding reactions
Documenting Patient Hx
Medical and surgical history
Family history
Social history
Female pt's histories will include Pregnancy tab, Male pt's histories will not
Medical Hx
Past Medical Hx
Past Hospitalization
Past Surgeries
Social and Family Hx
Safety in the Home
Paternal/Maternal Health Hx
Martial Status
Employment
Tobacco
Drug/Alcohol Use
Exercise Habits
Nutrition
Dental Hx
Pregnancy Hx
Previous pregnancies and significant reproductive Hx for female pts
Chief Complaint
CC or cc
The patient's main reason for seeking medical care
Only one CC per encounter
Should be recorded using the pt's own words
Acute conditions
occur suddenly and are usually severe but of brief duration
Ex. UTI's, Sinusitis, and fever
Chronic conditions
conditions that persist over a long time or are recurrent
Ex. Congestive heart disease, asthma, and MS
History of Present Illness (HPI)
the severity of the patient's condition will be assessed.
Symptoms: What are the troublesome symptoms (e.g., pain, breathing difficulties, dizziness)?
Duration: How long has the patient had the problem or illness?
Timing (Chronology): Have the symptoms be
Pain Scale
Fifth vital sign"
-Describes quality of pain on a scale of 1-10
Wong-Baker scale for children
Problem List
Part of meaningful use (MU) requirements
Allows provider to identify most significant health concern
Identifies disease-specific populations
Helps to evaluate standard measures for providers and organizations (MU program)
Identifies patients for possible
Medications
Patients may be on medications from more than one provider
Vital to keep the medication record current
Record reasons for discontinuing medications
Medication Reconciliation
Process of comparing the medication list in the patients EHR with the patients self report of the medications he or she has been taking
Immunization History
Documents for both childhood and adult
EHR is a good tool for tracking immunization history, and when new immunizations are due
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A tetanus vaccine should be given every 10 years, or less for those with open wound sites. The EHR can keep a running record
Items documented within the Immunization Record
Name of immunization
Name of person administering the immunization
Date given
Location of injection
Category
Manufacturer
Type
Expiration date
Lot number
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Documenting these details will assist the Physician in the event of an adverse pt reaction or a rec
Using the EHR for Patient Education
EHR contains health data collected over a long time, allowing the attentive clinician to identify long-term trends that indicate elevated disease risk
**Although the main purpose of the EHR is to document patient-physician encounters, the EHR is also a us
Guidelines for effective patient education
Speak with the patient in a quiet, well-lit area that offers as much privacy as possible
Take your time and don't rush as you explain the material
Provide both oral instructions and supplemental printed instructions from the EHR
Encourage the patient to a
Vital Signs
temperature, B/P, pulse, and respirations
Recorded at the start of every visit
Important part of the pt. visit because they can indicate the presence of illness or disease.
Anthropometric measurements
not considered vital signs but are generally obtained at the same time.
Height, weight, BMI, head circumference
postural blood pressure
(Posturals)
blood pressure readings taken in different positions: Recumbent, sitting, or standing
Order Entry
one of the best ways to decrease the amount of errors and protect pts
Ex. Medication orders, snellen exams, glucometers, urinalysis, EKG's, audio grams
Progress Notes
Accurately recording the details of a patient encounter ensures the highest level of patient care, decreases the risk of lawsuits, establishes evidence of illness, and documents the treatment plan.
(S)- Subjective
What the pt. tells you
"recorded in the Pt's own words"
Ex. The pt. might say "Pain radiates down my left leg".
(O)-Objective
Information that can be observed, measured, or collected (vital signs)
Ex. pt with leg pain may have a measurable elevation of pulse and loss of reflexes
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the forensic evidence of the the medical chart/it is what it is
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(A)-Assessment
Summation of the diagnosis or the impression of what's wrong with the patient
Ex. after examination a pain pt. the assessment might be that they are suffering from sciatica, possibly caused by a herniated disk in the lumbar spine
(P)-Plan
The steps the provider plans to take to treat the patient
Ex. the physician may order an MRI of a lumbar spine to check for a herniated disk or may opt to order physical therapy
(E)- Evaluation/Education
May not be always used by providers but it includes advice to pt's regarding treatments, advice to pts about disease, and future issues and response
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the provider documents the Hx, examination findinds, plan of care, and other observations made during th
Digital Signature
When a note is signed electronically, the provider is representing that everything within the note is correct
A notation of when it was signed and by whom is shown below the signature line on the saved note
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Although a batch of notes can be signed at onc
Problem List
Location of the pt. record where a summary of pt. diagnosis can be referenced
High Alert Medication
a medication that poses a heightened risk of injury or death when administered improperly
PFSH
abbreviation for past medical, family, and social hx
Review of Systems (ROS)
organized inventory of each organ system, completed as part of the initial pt interview to pinpoint any unusual findings in the pt's history
Documentation in the pt chart includes:
progress notes
vital signs
pt. letters
as a series of 3 injections
Hep B vaccination is administered?
include any OTCs the pt is taking
When entering medications in the EHR
acute
an illness that presents QUICKLY with a SHORT duration
vital signs
BP, temp, pulse, and respiration's are called?
a chief complaint
c/o dizziness" written in an EHR is
objective data
BP 126/84 mm HG" written in EHR is
assessment information
Pt has type 1 diabetes" written in EHR is
plan
Pt to be referred to an ENT specialist" written in EHR is
E-visit
a consultation with the doctor over a secure Internet service is called