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19 Cards in this Set
- Front
- Back
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ESSAY Name 3 things to do when making corrections |
use black ink don't use white out use one black line to omit verify change |
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3 benefits of EHR |
Less store space avoid medical errors Cost savor |
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Explain the concept of NEED TO KNOW and how it applies to the MA |
Don't look at anyone's chart unless vital to treatment |
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Describe the purpose and ownership of the medical record |
Its a detailed medical record of the pt. Pt owns the information but the facility owns the record. |
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A sign informed consent in a medical record indicates the patient understands and consent to the procedure |
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When sending an EHR alert |
Use proper grammar in terms do not include personal comments of the pt and the alert may become apart of the record
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After automated orders have been sent out |
Log off the system |
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If an EHR needs to be corrected |
Locate the error Verify the change Save the record |
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If a paper record needs to be corrected |
Use black ink |
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Active records |
are the records of pts that have been seen in the last 3 years |
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Inactive records |
Records of pts that haven't been seen in the last 3 years |
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Closed records |
Records of terminated pts |
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Digital signature |
provides encryption of a signature to prevent unauthorized use |
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Meaningful use |
Set of criteria indicating how a certified EHR should be used |
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SOMR |
Is a type of record where the contents are kept in sections |
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SOAP |
Is a method of charting a progress note |
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POMR |
Is a type of record that identifys a pts problems and organizes them |
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CPOE |
Provides the ability to order tests prescriptions and referrals using the computer |
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PHR |
Is health information stored electronically by the pt |
