SEMINAR 3

We now live in a world where almost everything is virtual and computerized. Medical record is one of the most important part of the office. Legal document and must be precise, accurate, and up to date at all times. NEVER to leave an office. Many people see the record, not just the Dr. Insurance companies, courts, clinical researchers, technicians, medical assistants, lawyers, other doctors.

* Subpoena: document that requires an * individual to appear in court * Subpoena duces tecum: subpoena for * documents to appear at a certain time and date *  either original taken in person or send copy *  never send original by mail * For pt: ONLY with written permission, NOT verbal. Not even to spouse, or family.

* Computerized medical records may contain: Operative reports, Physician orders, Laboratory results, x- RAYS patient demographics. Everything a paper chart has. *. * Advantages of using an electronic medical record? * Less storage space, Ease in analysis reporting, Flagging patients for recall. * The disadvantage is down time for training. GONE BY 2014

* Improve coding. * Reduce labor costs. * Lower malpractice insurance premiums. * Reduce transcription expenses. * Dramatically reduce storage space * requirements. * Reduce supplies. * When a medical records release form is received by the practice, records should be sent: 2 weeks * How do you make corrections in an EHR? * Pt has a right to ask their record be amended.- with proof. Example..my PCP had wrong DX.

Radiology uploads it, goes right to your Dr.

Hand held devices…..Dr can click on a RX, and it goes right to your pharmacy!

* How to Select a Computerized System * Establish the needs of the practice * Prepare a budget for the purchase * Establish a time line for shopping, purchase, installation, and final implementation * Prepare a request for proposal (RFP)

* Care/Studies-Show-Electronic-Medical-Records- Make-Financial-Sense/ ( look ½ way down page) Care/Studies-Show-Electronic-Medical-Records- Make-Financial-Sense/ * 19-billion-for-what.html 19-billion-for-what.html * hcare/EMR/ hcare/EMR/ FIELD TRIP ! Pick a door, come back in 10 mins to discuss

* Required length of time to keep medical records * Varies from state to state * General length of time: 7 to 15 years * Should be kept as long as patient is active * Deceased: 5 years * Pediatric: 7 to 10 years past majority (usually age 21) * X-rays/films: 5 to 10 years after patient is no longer * active