Transcript Electronic Medical Records

Chp 1
Electronic Medical
Records
Lesson 4:
Electronic Medical Records
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.
Lesson Objectives
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.
Electronic Medical Record (EMR)
 An electronic means of
gathering, charting, and storing
information
 Stored and accessed by
computer
Advantage of the EMR Accessibility!
Easily accessible
on a computer
Ability to access
any one patient’s file
from more than one
networked computer
in the office
Allow physicians to easily locate
patients’ laboratory results,
consultations, X-rays, and
examination findings from
other providers
Charting patient information
is made easier
Converting From Paper to
Electronic Medical Records
Takes time
scanner
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
Ensuring Patient Privacy with
the EMR
 Use password to access the medical
records
 logged off
 Computer screens must not be visible
to public
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
PDAs in the Medical Office
 hand-held, computer used as a personal
organizer
 physicians can carry from patient to patient
Benefits Gained Through Using the
EMR
 Electronic signatures
 Helps minimize medical errors
 Saves time
 Can be used with diagnostic
equipment
 Can improve communication
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