Discuss the functions health care records serve.A health record contains vital information about the patient, such as the patient’s health and treatment history.
Overview
A health record contains vital information about the patient, such as the patient’s health and treatment history. This week, you will identify the different health care forms used to keep patient information in the electronic health record (EHR). Some forms are completed by the patient, such as consent and medical history forms, while others are completed by the health care provider. You also will learn about the basic workflow of a health care organization that uses an EHR. Mapping out the workflow in the health care office allows organizations to analyze the current process for patient care and helps identify ways to maximize efficiencies.
What you will cover
Electronic Health Records (EHR)
Discuss the functions health care records serve.
Track patient information
Assist health care providers in providing patient care
In hospital settings the data flows into the EHR from the different departments systems
Labatory
Radiology
Pharmacy
Surgery
Identify different health care forms use to keep patient information in EHRs.
Patient
Consent forms
Medical history
Health care provider
Doctor’s notes
Outpatient forms
Lab forms
Insurance reimbursement forms
Discharge forms
Prescriptions
Referrals
Describe the basic workflow of a health care organization using EHRs.
The patient contacts health care provider and the appointment is scheduled
The patient arrives and is checked into the office
The demographic information is entered into the EHR
Insurance information is scanned into the EHR and insurance eligibility is confirmed
The patient completes a health history and current reason for the visit
The EHR specialist enters the data into the EHR for the medical staff to access during the visit
The patient is called to the exam room
The patient’s vitals are taken and recorded into the EHR. The nurse reviews the history and chief complaint for accuracy.
The physician enters and reviews the EHR
The physician uses the SOAP format to record the visit: Subjective, Objective, Assessment, and Plan
Subjective: The physician discusses the current problem with the patient and documents the discussion in the EHR
Objective: The physician performs the physical examination
Assessment: The diagnosis is determined and problem list updated
Plan: The plan of treatment is determined. The physician prescribes medications, treatments, or additional tests using the EHR.
If lab work ordered, the orders is sent electronically lab
Patient education is provided on the current plan of treatment
The patient is checked out using the EHR to schedule follow-up appointments
If requested, the EHR specialist sends out requests for records from specialist or additional physicians that provide care to the patient
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