eSignature Patient Medical Record Made Easy

E signature patient medical record

alright guys this is the first chapter to the new textbook the health of the electronic health record from the physician's office now this bulk runs hand in hand with some charts for the medical office which we use here on campus so this is a really good resource and if you are working towards your electronic health record certification this is the textbook that you really need to dissect and to digest and really understand what's going on here so we're gonna start with chapter one today and it's the introduction for the electronic health record some of the things that we're gonna talk about today are just going to be able to explore the history and current use of patient health records and their importance to individual's health and their contribution to the healthcare Network become familiar with content of a typical EHR system well-defined documentation and explain whose documents or who documents in the medical record we'll discuss the ownership of a health record we'll list and explain eight core functions of the knee har and we'll describe the basic functions and advanced clinical support decision software features of the EHR system will define practice management software and explain how it is used with an EHR system we'll discuss and describe advantages of advantages and disadvantages of an EHR system we'll discuss EHR adoption rates and who is using an EHR system will identify the roles of various healthcare professionals in the implementation of an EHR system and we'll investigate various professional organizations promoting the use of EHR systems so as we as most of us can gather and as you as you probably know technology nowadays is taking over and everything is turning over to the electronic format even medical records and that's what this is all about so we should be past the transition stage now of transitioning from paper medical records to electronic medical records however you might have a straggler or two there that will still be using the paper-based medicals their record system so basically what is a medical record a medical record is a physical collection of an individual's health care information now it can be everything and anything that goes on with that person health-wise and their they've been used throughout history to document patient health care signs and symptoms diseases and trends diseases now you first noticed health records being used way back and like 200 BC or something like that and it was some physician from China who just basically kept notes on the people that he was seeing and that's basically your first and and most simple form of a health record and then it really started to kick off in like 1892 to 1954 when Ellis Island was open and all these immigrants were coming to America to make America their home and medical records would be starting to take documents there they started to make documents into medical records to make sure that people were free of any communicable diseases like you see on the bottom one here and that's really where it started and then you can also see Hitler use them and not for the right purposes but he wanted to see the effects of how different types of chemicals and gases affected the human body so they kept notes and all those things so generally the keeping of medical records has been a really good thing for the medical field however as anything in this world there are a couple bad eggs there but nowadays everything is looking good and medical records are being used for the right purposes so what is in an electronic health record what's the content what is the guts of it so basically each patient has their own record and that is just a confirmation of everything that that patient has done health-wise and it's documentation is a vital component of an EHR system and it's important to note that everything is accurate and precise in those in that medical documentation it can contain health information administrative information you need a little even legal documents and we'll get into each one of those here in a bit but it's important to know that so some of the clinical information that can be seen in there you can have medication lists so what types of medications do you take do you take something for your your diabetes or are you anemic okay and then they put that in there are you allergic to anything if they document that immunization records have you ever been immunized with anything the heavy vaccination or something like that a laboratory report so anytime you got blood drawn or you had throat culture when you had a strep throat those would all be in their pathology reports anytime you had surgery or surgical reports Hospital reports Agent P is your history and physical examination yeah every time you go to the doctor and they ask you questions yeah those are gonna be there your progress notes your radiology reports x-rays those types of things so those are all everything that happens is going to be in a medical record it'll also have administrative information for you about patient information forms and that's basically asking you you the first time you go to the doctor's office and they give you a clipboard with a bunch of papers on it and say here can you fill this out and you have to check all the boxes yes or no if you ever had this that or the other thing that is a patient information form they're just trying to gather all the information they can on you to establish your health record it can be a referral letter sent from another doctor if your you work at a specialty clinic or or you're referring them to a specialty clinic you need to have referral letters and consultation letters it will have insurance information and billing information their appointment history they have diagnostic and procedural codes which I know you don't know much about now but you will know in the future and and you'll have emergency contact information in there as well so it really it covers everything and then the legal documents okay so on occasion a patient medical record may be used during court proceedings for malpractice lawsuits thorough and accurate documentation helps prove what went and why something happened so documentation guys is key I know we talked about it in your medicine and law and medicine and ethics sections in the administrative medical textbook okay but documentation is so essential to our job as administrative assistants in the medical field if you have if you want to see consent form look at figure 112 in the textbook and you can see it there and on the sim chart for the medical office if you click on the form repository button or icon there you can basically go in and review forms listed on the left side panel into legal administrative and clinical documents and there will be a ton of them there and we'll get into that more in the future here but some of the legal documents er gonna be in medical records release form or consent document you can have HIPPA forms advanced directives living wills insurance authorization forms and healthcare power of attorney forms so there's a ton of forms guys that that all are going to be essential in the delivery of health care to your patients so some of the documents for documentary for a medical record so what I want you to do here is just think about the type of health career that you have chosen to to venture into whether it's just a medical administrative assistant whether it's you were looking into being a medical administrative assistant with electronic health records or billing and coding or do you want to do it all just think about this when you're doing this ok so individuals who are responsible for inputting information into the medical record are known as the documentary ok they can be receptionists that can be medical assistants physicians or other treating professionals and medical billers so really it's everybody in that in that medical office needs to be able to utilize these electronic health records and its structured data entry and free-text documentation so a lot of its gonna be templates where you just import data into these templates and checkboxes and and click radio buttons but some of it you're gonna have to type in and do that free text documentation as well so it's a mixture of both ownership of the medical record alright this is a good one to know and it's really important this question will come up a million times who owns the medical record ok now it's the property of the individual who created it therefore the physician's office owns the medical record now the patient loans the information in the medical record but the physician owns the actual physical record now the patient can obtain a copy by signing a records release form and pulling that information however they may be charged administrative fees for having to go through the process this isn't get that all done now there's such things called as doctrine and professionalism a professional discretion okay so basically this is a principle that states that a physician can exercise his or her best judgment when deciding whether to share progress notes and clinical observations with a patient who is being treated for mental or emotional disturbances the doctrine of professional discretion is intended to protect mentally or Lille patients from any additional harm that viewing their medical records could cause so if if your page if you're dealing with patient has mental or emotional issues or disturbances it might be in the best interest to that patient to withhold some information from them there and that is known as the doctrine of professional discretion so let's talk it look a little bit more into the electronic health record so the patient medical record is in an electronic form now and you'll see when we get into the actual sim charts which you'll start playing around with more next chapter and you get into that you'll see that everything is there everything is housed there so ideally the EHR is an exchange that the EHR can exchange data freely with other computer systems such as other health care providers pharmacies hospitals laboratories and insurance companies creating one central electronic health record that is easily accessible to authorized parties yes secure enough for those from those who don't have the right to see it okay and there are eight core functions of an EHR system if you look on this slide here they are we'll go over them a little bit more here but in 2003 the US Department of Health and Human Services or DHHS asked the Institute of Medicine to create a set of standards for for EHR systems in response the IOM or the Institute of Medicine outlined the above are these eight core functions of an EHR system alright and this health information and data management you have results management order management decision support the electronic communication in connectivity patient support administrative papas processes and reporting and pipe reporting in population health so what I want you guys to do is is look on page 10 in your electronic health records textbooks for more details on each of those eight functions and really educate yourself on these points okay now medical records weren't always electronic we never had the technology available to us to have that that luxury of having them so there is a transition period from transitioning from paper to electronic 'el records so the Bush administration yeah back when President Bush was in office declared 2004 to 2014 the decade of hit or a chai tea now what does hit stand for it stands for health information technology if you look on the next line right there okay so the office of the National Health National Coordinator of the health information technology or the O n CIT promotes universal meaningful use of EHRs so for example computerized physician order entry x' see CPOE they developed and established that and they were really ones that started to push from the transition from paper medical records to electronic medical records now there is a difference between electronic health records and electronic medical records all right so the terms EMR and EHR tend to be used interchangeably however there is a difference so if you were explaining trying to explain this to somebody who has never heard the difference the easiest way to do that is to say that an EMR system is the electronic patient record created and maintained by a single provider wire an EHR system is interconnected aggregate of all the patient's health records so it's everything and it can be shared to multiple sources all right so the EHR system is interconnected aggregate of all patients health records it has that data from multiple providers and the data from multiple healthcare facilities where the EMR system is the electronic patient record created and maintained by a single provider okay so here are some basic functions of an EHR system so most EHR systems have some basic functionality with differences in text execution navigation workflow and so forth because their fundamental features are similar the user can adapt to different systems with very little difficulty so if you guys become proficient and efficient here on center using sim cards no matter what medical office you go to you shouldn't have a terrible time transitioning to their program so the Center for the medical office which is called CMO E or C SCM oh I'm sorry is a web-based EHR that has real functionality used in physicians offices and outpatient facilities while giving you guys the students a safe and academic learning environment it will be referred to about this text and it we really go hand in hand with that you guys will be using consent charts a ton throughout the entire medical office program here so really grasp it really try to understand the concepts and if I were to give you a task and say can you do this for me I want you to be able to by the time you leave here on sin or be able to just jump on that that's that EHR system and navigate it and execute that task presented to you so here are some basic EHR functions you can do progress notes there's documentation templates whether it's a certificate certificate to return to work or something along those lines you have provide a review of incoming data you'll have images attachment you'll be able to have an electronic signature insertion you have prescription templates you'll fax again next messaging patient reminders vital science data importation of data you have automatic flagging emailing from their printing from their so it really will do everything that you need to have to make your office run efficiently so clinical decision support or CD s so basically this allows providers to set protocol for specific patients and/or conditions now the CD f2 will only work if the provider takes advantage of them so but based on evidence or based on evidence-based treatment protocols it's it basically gives the patient's automated preventive care reminders it will set up treatment plan templates it will generate patient data reports and and it will have more documentation templates for you as well this is a really good thing that you want your your physicians to be involved in it really helps bridge that gap between the patient and physician and it offers them that documentation and support that they should be easily able to understand and use their benefit and then you have practice management software and and basically practice management of software allows the electronic management of the business side of the practice so this is really where we focus on as administrative medical assistant so you'll have some administrative software used for patient demographics and then you'll get into billing and insurance information scheduling their appointments and then you have advanced accounting procedures so these tasks are now incorporated as part of the EHR I know it's really hard to see on here but here are some administrative source documenting this right here is a let me see what it if I can see oh this is just a patient information form so they this is thought this is something a template that you would get on and just fill out the blocks you know with a patient information form adding their last name their basically their demographic information their insurance carriers their driver's license their social security number those types of things here so an SCM oh so it's in check for the medical office patient demographic screen is still shown here and basically the patient demographics tool in the sim chart for the medical office stores all of the information on three tabs whether it's a patient the guarantor and insurance tabs and you guys want plenty of time to get in there and play with that and learn more about those they're some advantages of EHR system so why is it good to have an electronic health records in your in your physician's office or over in your hospital and basically there's many reasons it's improved quality and continue it can keep continuity sorry so it's improved quality and continuity of care so management of chronic diseases and disaster preparedness it just it really helps make those more efficient if it's increased efficiency it's improved documentation it's easier accessibility at the point of care there's better security it reduce overall expenses of the practice and it's it's makes the mind at your job and the patient's job more satisfactory but the one that sticks out the most is the most advantageous and most important to the to the patient would be the valued improve quality and continuity of care as well as the improved efficiency of visits you know getting their time in there making moving quickly getting a lot done in a short amount of time really will help that patient and they're more out throw up that dog that about that doctor's appointment now continuity of care is the transition from one position to another of a patient so if you know a patient comes to you and you need to refer them out to another provider to see a specialist of some sort having that bridge of the electronic health records you know and just being able to send them there tronic health record or relieve some information to them really helps them pick up right where you left off and continue back to care for the patient some addition antigens though so there there are a couple competitive compatibility standards have not yet been universally applied to ensure that systems can interact with or talk to one another so this capability is known as interoperability so the lack of interoperability among some products so some medical electronic health records might not talk to other electronic health records and that could be a disadvantage of that for sure so this is a lack of uniformity that has become a real dilemma for both the individual patients and for the US healthcare system as a whole if a hospital uses a different EHR system from that of the patient's primary care physician the patient's health records may not be available to the hospital or vice versa some other ones which are less disadvantageous I guess would be initial cost it's a big financial investment to get this up and running and then it takes a lot of time to implement it as well employer resistance you know you might have those employees that are comfortable in it with their jobs and the way that things were going with the paper medical records and they might not want that change regimentation is security gaps are a couple more so early versus late adopters so mainly a recent large study showed that most those most likely to adopted EHRs early were primary care physicians physicians practicing in large groups and specialists generally recent healthcare graduates are more likely to report overall satisfaction with EHR usage because that's the way they learned throughout their college courses or or throughout their their educational experience they've used technology to their advantage so being able to transition you know having a college aged student transition into using EHR systems now is is easy for them so the following factors could affect user satisfaction it could the lengths of systems or response time so if your computer is slow the perception of workflow logic okay ability to complete tasks 'is a mistake correction training time availability of support staff system effect on quality of care ability to convert systems to specific provider needs and a level of computer skills so those will all play a factor in how satisfied you are with EHR systems so the roles of health care professionals see the EHR has many users within the healthcare environment and it will have an effect on all areas of the medical office physicians nurses physician assistants medical assistants and medical coders and billers all must be exposed to the EHR alright and all the learning new software may be difficult and time-consuming it is important to keep patient care front and center at all times as yes they are the reason why we treat you know we work we treat patients every day so some of the basic skills you need to know you need to have knowledge and medical terminology alright every part of the healthcare is important and this is no exception you need to be able to understand the medical language and if you don't understand the medical language you're gonna really struggle through this basic typing and computer skills yes you need to get comfortable it takes time but you can get it and everything is electronic now so if you don't like using technology and electronics you know this might not be the field for you organizational skills okay you need to prepare yourself to go paperless because everything is getting paperless even even checking in with a doctor and the doctor's notes in the exam room yeah those are being done on iPads and having different things like that and then you need to have interpersonal skills you need to be able to help patients through this transition too because you might get an older geriatric patient that comes in and has never seen an iPad before and you ask them to register on it and they're wondering what exactly you're typing in and who you're sending it to and so you need to help the patient's through that transition and really try to ease it and make it easy for yourself some administrative duties that you're going to see so we had administrative we had clinical and we had legal duties at the very now we're going to get into each one of these so the adoption of an EHR system affects many of the administrative duties within the medical office medical office personnel will need to adapt to these changes to ensure smooth transition from paper-based records to each our systems the EH artist purchase in a generic format and it must be customized to fit the given office an orthopedic office might not have the same information and set up as a gynecology office so it really just depends on what the purpose of your office is doing so represents a large chunk of administrative work in the medical office so here are some of the duties that can be done on EHR systems for the administrative aspect we have a receptionist duties appointment scheduling electronic chart creation per G entering patient data creating patient letters email communications patient education and then the coordination of care some clinical duties okay so the EHR can be customized to ensure that all components of the patient says it are well documented so you can document treatments you can coordinate patient care and then you can document the patient history and physical examinations their vital signs data progress notes which are basically the details of the patient's visit now we can talk about laboratory requisitions prescriptions test results all that stuff is going to be stored in an electronic health record guys and then some billing and coding duties that you're going to have to do so a fully integrated EHR and practice management system allows the user to review the clinical documentation that we just talked about and then prepare claims for submission off of it so data from patient demographics and super bill or encounter forms are populated into the insurance claim and then sent out for reimbursement to the medical office for the services rendered so you have two people you'll be able to create billing statements you'll sign procedural and diagnostic codes you'll link codes for reimbursement do auditing and filing patient statements so really guys everything that happens in the medical office is going to be documented and and then shown on this electronic health record and as I said earlier it is essential to have good patience skills because that is our job as medical administrative assistants yet everything is about documentation making sure everything is correct and well-organized and that is probably the most important thing in our job other than confidentiality here so professional organizations now there's there's many benefits to becoming involved with professional organizations they can offer you other certification exams they can give you CEU opportunities or continue into education units there's chances for networking and getting yourself out there as a medical administrative assistant it may be growing through the the career field there there's newsletters and professional journals that are sent out you up discounts on publications they'll sponsor conferences workshops and web-based activities so learning should be lifelong especially in a constantly changing environment like healthcare so getting involved in these professional organizations here will really help bridge that gap between your learning here and then you're learning fifteen or twenty years down the road okay so get involved in one of these or multiple of these professional organizations after you leave this program here and really continue your education you have a team on here which is the American Health Information Management Association you have American Academy of professional coders which is that HPC you'll have the American Association for medical assistance to the AMA or the AMT which is the American Medical technologists group there and that is gonna end our slide for today if you have any questions please feel free to come ask me up here I'm more than willing to help in any way that I can you know really try to dice digest this information that's presented to you guys and and use this lecture to just reinforce the book okay this this lecture is just an outline of the material that's covered in the book you really need to get in there and you know to try to dig deeper and dive deeper into that information alright have fun and good luck guys