A health record contains vital information about the patient, such as the patient’s health and treatment history. This week, you will identify the different health care forms used to keep patient information in the electronic health record (EHR). Some forms are completed by the patient, such as consent and medical history forms, while others are completed by the health care provider. You also will learn about the basic workflow of a health care organization that uses an EHR. Mapping out the workflow in the health care office allows organizations to analyze the current process for patient care and helps identify ways to maximize efficiencies.
What you will cover
0. Electronic Health Records (EHR)
a. Discuss the functions health care records serve.
1) Track patient information
2) Assist health care providers in providing patient care
3) In hospital settings the data flows into the EHR from the different departments systems
b. Identify different health care forms use to keep patient information in EHRs.
a) Consent forms
b) Medical history
2) Health care provider
a) Doctor’s notes
b) Outpatient forms
c) Lab forms
d) Insurance reimbursement forms
e) Discharge forms
c. Describe the basic workflow of a health care organization using EHRs.
1) The patient contacts health care provider and the appointment is scheduled
2) The patient arrives and is checked into the office
3) The demographic information is entered into the EHR
4) Insurance information is scanned into the EHR and insurance eligibility is confirmed
5) The patient completes a health history and current reason for the visit
6) The EHR specialist enters the data into the EHR for the medical staff to access during the visit
7) The patient is called to the exam room
8) The patient’s vitals are taken and recorded into the EHR. The nurse reviews the history and chief complaint for accuracy.
9) The physician enters and reviews the EHR
10) The physician uses the SOAP format to record the visit: Subjective, Objective, Assessment, and Plan
11) Subjective: The physician discusses the current problem with the patient and documents the discussion in the EHR
12) Objective: The physician performs the physical examination
13) Assessment: The diagnosis is determined and problem list updated
14) Plan: The plan of treatment is determined. The physician prescribes medications, treatments, or additional tests using the EHR.
15) If lab work ordered, the orders is sent electronically lab
16) Patient education is provided on the current plan of treatment
17) The patient is checked out using the EHR to schedule follow-up appointments
18) If requested, the EHR specialist sends out requests for records from specialist or additional physicians that provide care to the patient
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