HSC151 Final Exam Review 2

Final Exam
Review
HSC 151 – Introduction to
Electronic Health Records

How do you search for Patients in Neehr Perfect?


Scroll Down and Find name


Type Last Name, Click OK
 Double



Click on Name in List

Type in Last 4 digits of SS number

Where do you find the latest set of vitals?
 On

the Cover Sheet tab, Be sure to double click to reveal all.

Flagged items are found on the orders tab

Notes are located on the notes tab and should be read for details that may not be included in the proper location.

Where do we find consult information??
Does the patient have any clinical reminders?? Where are inactive problems located???
Do all active problems trigger Clinical
Reminders? Yes or No Explain

Clinical Reminders
Clinical reminders are decision support tools that assist health care providers and health care systems to implement recommended actions and practices. Reminders can direct clinicians to perform certain tests or to provide treatments appropriate for specific populations. Reminders are particularly useful for ensuring completion of tasks that may be overlooked while attending to more acute issues or specific patient concerns. Electronic clinical reminders can also allow providers to easily view when certain tests or evaluations were performed, as well as documenting when the associated care has been delivered. The Clinical Reminder software demonstrated in the Neehr Perfect
EHR, was developed for the VistA EHR system as part of the Veteran
Health Administration’s (VHA) effort to implement clinical practice guidelines. Clinical reminders have proven successful in assisting
VHA to achieve high levels of compliance with prevention and chronic disease management standards. They have been universally adopted across VHA Primary Care and in many other services.

Questions to think about
Explain what an EHR is and it’s importance to
Healthcare?
What is government’s role in EHR systems?
What are Clinical Reminder?
Define “Meaningful Use” from a provider and patient prospective. Explain “Information Technology” role in an EHR.
What is “Data Mining”? Explain

EHR Transitions
Healthcare organizations are transitioning from paper data entry and data storage to health information technology
(HIT), including electronic health records for the management of health data. Two key reasons why healthcare is encouraged to adopt and meaningfully implement EHRs are the EHR is promised to provide more complete and accurate information that is more easily accessible and retrievable.
Properly entered electronic health data enables search, retrieval and comparison across patient populations over time in a process called data mining. This carefully extracted data can be used for meaningful research to improve individual patient care and best practices in healthcare delivery. The key to unlock the powerful potential of the EHR is the careful and consistent entry of data into retrievable areas, or fields, also referred to as coded data fields.

Benefits to implementing an
EHR
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Improved quality and continuity of care
Management of chronic disease
Disaster preparedness
Job & patient satisfaction
Increased efficiency
Improved documentation
Easier accessibility at point of care
Better security
Reduced expense

Disadvantages to implementing an EHR
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Lack of interoperability
Cost
Financial investment
Time
Employee resistance
Regimentation- (rigid organization for regulation or control)
Security gaps

Explain WHO owns the information in a EHR.
Ownership of the Medical Record
Property of the individual who created it
Physician office owns the physical record
Patient owns the medical information
May obtain a copy by signing a records release
May be charged an administrative fee

Explain the Difference between EMR and EHR
EHR
Interconnected aggregate of all the patient’s health records  From multiple providers  From multiple healthcare facilities


EMR
 Electronic

patient record created & maintained  Component of the
EHR

Happy Studying and Good Luck on your Final Exam!