Electronic Medical Record (EMR)

Digital version of the paper chart in the doctor's office.

Electronic health record (EHR)

Digital version of the patients’ total health information in one record.

5 Cs of Documentation

• Concise. • Complete (and objective). • Clear (and legibly written). • Correct. • Chronologically ordered.

Modifications to Medical Records

• Draw a line through incorrect information so that it is still legible. • Write in the correct information. • Sign or initial, date, and time the entry. • If possible, have a witness also sign or initia

New documentation used to add information to the original entry in the written document.

Used to clarify or correct information in the electronic health record.

Ownership of Medical Records

Medical records are owned by the facility that created them

Doctrine of professional discretion

Health care professionals have the right not to release a record if it is in the best interest of the patient.

Retention and Storage of Records

Medical records are kept until specified statute of limitations, usually 2 to 7 years for adults

Destruction of the Medical Record

No single standard for the destruction of records

Routine Release of Medical Information

• Insurance claims. • Transfer to another physician. • Use in a court of law.

Providing Medical Information for Lawsuit

• Make sure name, phone number of attorney, and court docket number of case are listed.

Alcohol and Drug Abuse Records

Federal law protects patients with histories of substance use disorder

Authorization to Release Records

Authorization should be in writing.

Health information technology (HIT)

refers to the electronic systems health care professionals—and patients—use to store, share, and analyze health information

HIT and Meaningful Use

Stage 1 (2010 to 2013): Adoption by providers of certified EHR systems and e-prescribing.

Health information technology is intended to: • Create faster, more accurate prescriptions

A portal is a secure website for the patient through the providers’ office or health system

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Chapter-7

Term	Definition
Electronic Medical Record (EMR)	Digital version of the paper chart in the doctor's office.
Electronic health record (EHR)	Digital version of the patients’ total health information in one record.
5 Cs of Documentation	• Concise. • Complete (and objective). • Clear (and legibly written). • Correct. • Chronologically ordered.
Modifications to Medical Records	• Draw a line through incorrect information so that it is still legible. • Write in the correct information. • Sign or initial, date, and time the entry. • If possible, have a witness also sign or initia
Addendum	New documentation used to add information to the original entry in the written document.
Amendment	Used to clarify or correct information in the electronic health record.
Ownership of Medical Records	Medical records are owned by the facility that created them
Doctrine of professional discretion	Health care professionals have the right not to release a record if it is in the best interest of the patient.
Retention and Storage of Records	Medical records are kept until specified statute of limitations, usually 2 to 7 years for adults
Destruction of the Medical Record	No single standard for the destruction of records
Routine Release of Medical Information	• Insurance claims. • Transfer to another physician. • Use in a court of law.
Providing Medical Information for Lawsuit	• Make sure name, phone number of attorney, and court docket number of case are listed.
Alcohol and Drug Abuse Records	Federal law protects patients with histories of substance use disorder
Authorization to Release Records	Authorization should be in writing.
Health information technology (HIT)	refers to the electronic systems health care professionals—and patients—use to store, share, and analyze health information
HIT and Meaningful Use	Stage 1 (2010 to 2013): Adoption by providers of certified EHR systems and e-prescribing.
HIT Intent	Health information technology is intended to: • Create faster, more accurate prescriptions
Patient Portals	A portal is a secure website for the patient through the providers’ office or health system

Created by: user-2045463

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