Key Principles of Health Information Systems Standard11.1

What is an EHR/EMR EHR/EMR is more than a computerized version of a paper chart. It is a comprehensive digital record of patients information. The EHR/EMR allows patient information to be shared with other healthcare providers, i.e., laboratories, specialists, pharmacies, etc.

Benefits of EHR/EMR Track data over time. Identify patients who are due for preventative visits and screenings. Monitor how patients measure up to certain parameters, such as vaccinations and blood pressure readings. Improve overall quality of care.

Types of Data Collected in EHR/EMR Billing information Patient demographics Progress notes Vital signs Medical histories Diagnoses Medications Immunization dates Allergies Radiology images Lab and test results

Personal Medical Devices Self-care medical devices play a major role in providing personal care that will help individuals to manage acute and chronic illnesses. Personal medical devices are emerging as the next wave of personal health data collection used for EHR/EMR. They are portable, consumer-focused technologies that assist with remote monitoring. They can be used at home for health and fitness supervision, chronic disease management, and elderly patient monitoring.

Health Record Collection Tools Glucose monitors ECG monitors Pulse oximeters Heart rate monitors Sleep apnea monitors Blood pressure monitors Telemedicine 24 hour / 7 days a week communication between clinicians and patients. Comprehensive review of a patient’s electronic health record. Phone applications iBlueButton Track My Medical Records Capzule PHR My Medical

Content of EHR/EMR General Components Patient registration Consults Assessments Care plans / Progress notes Orders Pharmacy Laboratory Radiology Services Procedures Legal documents / Authorizations and consents

EHR/EMR Components - Procedure Surgical procedure Outpatient procedure Invasive diagnostic study Bedside procedures Imaging Special studies Practitioner notes Provider observations Identifying information Health history Physical exam

EHR/EMR Components – Physical Exam General status Vital signs Skin Head Ears Eyes Nose Mouth/tooth/throat Chest/lungs Breast Heart

Health Record Authentication Record contains sufficient information to identify the patient, justify diagnoses and treatment, document results of care or treatment, describe the condition of patient upon discharge, and document instructions to the patient. Entries must be accurate, relevant, timely and complete. Irrelevant text should be omitted; notes should be concise. Appropriate note titles must be matched to note content and the credentials of the author. Notes must be reviewed and signed promptly.

Health Record Authentication EHR/EMR users must respond quickly to notifications. Copy and paste must be used with caution and according to policy. Identity and professional discipline of the author, the date, and the time signed. No edit or alteration of any documentation r electronic signature, which has been completed, can occur without approval of the HIM Director. The author must initiate any retraction or rescission of any entry or originating discipline, i.e., laboratory. An addendum to a note may be made when a healthcare provider deems it necessary to clarify information recorded in the original document or to add to the original document.