Lab and test results
+ reduces patient waiting time
+ avoids letters and phone calls
-may confuse and worry patients
-must ensure sensitive results (cancer or HIV) are given in person or on telephone Medication management (with refill requests)
+ allows patients to check and improve quality of medication list (medication reconciliation)
+ encourages discussion with doctor to improve adherence
+ patient can share medication information with other
providers
-may be incomplete or inaccurate if medications are from multiple prescribers Appoint view (upcoming and history)
+ keeps track of upcoming care
+ reduces number of missed/cancelled appointments Appointment request
+ greater patient control and avoids tedious phone scheduling
- may be challenging for the health system to offer open access and appointment may not match the level or type of care needed After patient summary
+ helps patient recall
discussion during clinical encounter and helps reinforce clinical advice
+ information can be shared with caregivers Clinician-visit summary
+ patients better understand clinician thinking, decision making, clinical issues, and treatment options
- language may be confusing or misunderstood to patients and clinicians may resist shared notes, citing patient harm and need to alter notes Clinical reminders
+increases patient adherence to preventive care Secure
messaging
+ convenient 24/7 access
+ avoids telephone tag
+ can include in medical record
- fitting messages into workflow
-reimbursement lacking
-need patient education to prevent inappropriate use (urgent issues) Self-entered data
+ importante data complementary to EHR information
+ helps patient see trends needing attention (rising blood pressure)
- patient may incorrectly assume provider is viewing the information
- unclear how to integrate with EHR Proxy
use (delegation)
+ allows sharing information and care with caregiver
- patient may inadvertently release information intended to be private Administrative
+ helps manage care and finances
+ improves knowledge of benefits 1. Make sure you know the office policy regarding charting. Find out who is allowed to write in the chart and the procedures for doing so. 2. Make sure you have the correct patient chart. If the patient's name is common, ask for a birth date or social security number as a double check. 3. Document in black ink only. 4. Sign your complete name and credentials. 5. Always record the date of each entry. Some outpatient facilities record the time as well. Using
military time will eliminate the need to use AM and PM. 6. Write legibly. Printing is more legible than cursive writing. 7. Check spelling, especially medical terms, before entering them into the chart. 8. Use only abbreviations that are accepted by your facility. Because abbreviations can cause confusion and errors in patient care, the use of certain handwritten abbreviations has been prohibited by The Joint Commission. 9. When charting the patient's statements, use
quotation marks to signify the patient's own words. 10. Do not attempt to make a diagnosis. it is not within the scope of your training to diagnose. 11. Document as soon as possible after completing a task to promote accuracy. 12. Document missed appointments in the patient's chart. Chart your attempts to reach the patient to remind him or her of the appointment. 13. Document any telephone conversations with the patient in the patient's chart. 14. Be honest. If you
have given a wrong medication or performed the wrong procedure, as soon as the appropriate supervisor is notified, document it, and then complete an incident report. State only the facts, do not draw any conclusions or place blame. 15. Never document for someone else, and never ask someone else to document for you. 16. Never documents false information. 17. Never delete, erase, scribble over, or white out information in the medical record because this can be construed as
attempting to cover the truth and tampering with a legal document. If you do make an error, draw a single line through it, initial it, and date it. Then write the word "correction" and document the correct information. Terms in this set (210)1. Enter the request in the ROI database: information such as patient name, date of birth, health record number, name of requester, address of requester, telephone number of requester, purpose of the request, and specific health record information requested is entered in the computer.
2. Validity of the authorization is determined: The HIM professional will
compare the authorization form signed by the patient with the facility's requirements for authorization to determine the validity of the authorization form. The facility's requirements are based on federal and state regulations. Certain types of information such as substance abuse treatment records, behavioral records, and HIV records require specific components be included in the authorization form per state (varies per state) and federal regulations. If the authorization is determined to be
invalid, the request is returned to the requester with an explanation as to why the request has been returned. If valid to next step.
3. Verify the patient's identity: HIM professional must first verify that the patient has been a patient at the facility. Verification is done by comparing the information on the authorization with information in the master patient index (MPI). The patient's name, date of birth, social security number, address, and phone number are used to verify the identity
of the patient whose record is requested. Patient's signature in the health record is compared with the patient's signature on the authorization for release of information form.
4. Process the request: the record is retrieved and the only information authorized for release is copied and released. The Joint Commission (TJC) and state licensing bodies as well as Medicare Conditions of Participation (MCoP), National Committee for Quality Assurance (NCQA),
American Accreditation Health Care Commission/Utilization Review Accreditation Commission, American Osteopathic Association, Commission on Accrediitation of Rehabilitation Facilities, Health Accreditation Program of the National League of Nursing, College of American Pathologists, American Association of Blood Banks, American College of Surgeons, Accreditation Association for Ambulatory Health Care, and American Medical Accreditation Program. The Joint Commission offers an accreditation program
for hospitals and other healthcare orgs based on pre-established accreditation standards. -HIM manager would have enterprise or facility wide responsibility for HIM.
-Clinical Data Specialist perform data management functions in a variety of application areas including clinical coding, outcomes management, specialty registries, and research databases.
-Patient Information Coordinator: perform new service roles that help consumers manage their personal
health information, including personal health history management, ROI, managed care services, and information resources.
-Data Quality Manager: perform functions involving formalized continuous quality improvement for data integrity throughout the enterprise
-Data Resource Admin: responsible for the net generation of records and data management using media such as the CPR, data repository, and electronic warehousing.
-Research and Decision Support Analyst: support senior management with
information for decision making and strategy development.
- Security Officer - manage the security of all electronically maintained information, including the promulgation of security requirements, policies and privilege systems and performance audits. Sets with similar terms | 
