2. Key Principles of Health Information Systems Standard11.1

3. 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.

4. 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.

5. 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

6. 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.

7. 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

8. 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

9. 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

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

11. 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.

12. 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.