Lecture Electronic health records for allied health careers: Chapter 3 - Susan Sanderson

Chapter 3 - Electronic health records in the physician office. After studying this chapter, you should be able to: List the five steps of the office visit workflow in a physician office; discuss the advantages of pre-visit scheduling and information collection for patients and office staff; describe the process of electronic check-in;...

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Chapter 3

Electronic Health Records in the Physician Office

Records for Allied Health Careers

Learning Outcomes

After studying this chapter, you should be able to:

1 List the five steps of the office visit workflow in a

physician office.

2 Discuss the advantages of pre-visit scheduling and

information collection for patients and office staff.

3 Describe the process of electronic check-in.

4 Explain how electronic health records make documenting

patient exams more efficient.

5 Explain what occurs during patient checkout.

Learning Outcomes

After studying this chapter, you should be able to:

6 Explain what two events take place during the post-visit

step of the visit workflow.

7 Describe the advantages of computer-assisted coding.

8 List three decision-support tools the EHRs contain to

provide patients with safe and effective health care.

9 List four important safety checks that an EHR’s

e-prescribing feature can perform when a physician

selects a new medication for a patient.

Key Terms

• chronic diseases

• clinical guidelines

• computer-assisted coding

• decision-support tools

• disease management

(DM)

• formulary

• point-of-care

Patient Flow

• progression of patients from the time they make

an appointment until they leave the office after a

visit Whether paper-based or electronic health

records are used, the basic steps are the same

Patient Flow Steps

• Step 1: Pre-Visit: Appointment Scheduling and

Information Collection

• Step 2: Patient Check-in and Payment Collection

• Step 3: Rooming, Measuring Vital Signs, and

Patient Examination and Documentation

• Step 4: Patient Checkout

• Step 5: Post-Visit: Coding and Billing, and

Reviewing Test Results

Coding and Reimbursement

• Documentation and coding plays a major role in

whether a payer approves claims and reimburses the physician

• Computer-assisted coding uses software to

facilitate claim processing

Clinical Tools in the EHR

• Decision-Support Tools

• Tracking and Monitoring Patient Care

• Screening for Illness and Disease

• Identifying At-Risk Patients

• Managing Patients with Chronic Diseases

• Improving the Quality and Safety of Patient Care with Evidence-Based Clinical Guidelines

• Institute of Medicine recommends the use of

e-prescriptions by all providers and pharmacies by 2010

• Keeping Current with Electronic Drug Databases

E-Prescribing Benefits

Increasing Prescription Safety

• Drug-Allergy Conflict

• Drug-Disease Conflict

• Incorrect Dosage

• Incorrect Duration

• Drug-Pregnancy Conflict

• Drug-Age Conflict

• Drug-Gender Conflict

• Drug-Drug Interactions

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