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Chp 1 Electronic Medical Records Lesson 4: Electronic Medical Records.

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1 Chp 1 Electronic Medical Records Lesson 4: Electronic Medical Records

2 Lesson Objectives Upon completion of this lesson, students should be able to … Distinguish between the use of electronic medical records and paper medical records. Understand how to convert from paper to electronic medical records. Discuss the steps required to properly destroy a paper medical record after it has been converted to electronic format.

3 Lesson Objectives Provide an example of HIPAA compliance with regard to the use of electronic medical records. Describe the use of personal digital assistants with electronic medical records. List the benefits of using electronic medical records. Explain the steps to correct a mistake in the electronic medical record.

4 What would you do? Read scenario on page 27 and be prepared to discuss

5 Electronic Medical Record (EMR) An electronic means of gathering, charting, and storing information Stored and accessed by computer

6 Easily accessible on a computer Allow physicians to easily locate patients’ laboratory results, consultations, X-rays, and examination findings from other providers Ability to access any one patient’s file from more than one networked computer in the office Charting patient information is made easier Advantage of the EMR - Accessibility!

7 Converting From Paper to Electronic Medical Records Takes time scanner

8 Converting From Paper to Electronic Medical Records (cont) Once transferred to the EMR, the paper record is shredded may choose to store the paper record in a secure location rather than destroy Addition documents may be added using a scanner

9 Ensuring Patient Privacy with the EMR Use password to access the medical records logged off Computer screens must not be visible to public

10 Data Backup System Mandated by HIPAA Must be used on a daily basis not likely to lose computer data, even if the entire computer system goes down

11 Study Guide (aka workbook) Evaluation of Learning Page 10 Questions 45-53 Write in book!

12 PDAs in the Medical Office hand-held, computer used as a personal organizer physicians can carry from patient to patient

13 Benefits Gained Through Using the EMR Electronic signatures Helps minimize medical errors Saves time Can be used with diagnostic equipment Can improve communication

14 Read & Discuss Read NurseZone article Be prepared to discuss

15 Critical Thinking Question 1. How can the EMR help to avoid the occurrence of medical errors?

16 Avoiding Medical Errors (FYI) EMR can be used to alert health care providers to possible medication reactions EMR software typically has a safeguard mechanism built in that alerts the prescribing physician to any contraindicated medications a particular patient may be taking Studies have found that medical errors are caused by indecipherable or unreadable handwriting, a problem that would be eliminated if providers made their entries electronically

17 Green Cd-rom Admin procedures Chp 6 Computers and HIPPA Questions

18 Availability of Medical Records Online patients can look up portions of their EMR via the Internet laboratory results, dates of immunizations, or history of medications prescribed

19 Video Procedure 1-2 Saunders Release of medical information Answer questions page 15 Show work for Credit

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