Y khoa, y dược - Chapter 12: Advanced ehr functionality

Chapter 12Advanced EHR Functionality© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-HillChapter 12 ContentLO 12.1 Diagnostic TestsLO 12.2 Chart EvaluationsLO 12.3 Addenda to a Nurse NoteLO 12.4 Printing a Nurse NoteLO 12.5 Exporting and Printing the ChartLO 12.1 DIAGNOSTIC TESTSLO 12.1 Diagnostic TestsProcessing diagnostic testsProvider orders testIf Computerized Physician Order Entry (CPOE) not in use, personnel submit order to appropriate departmentImagingLabDiagnostic department performs test Results entered into EHRResults available to nurse/providerLO 12.1 Diagnostic TestsCommunication of diagnostic test resultsMost EHRs have alerts for abnormal resultsPrimary provider must be notified of most abnormal resultsNursing judgment requiredNurse must know underlying etiology and patient trendsLO 12.1 Diagnostic TestsCritical testsDelineated by facilityRequires that provider notified of results even if normalCritical resultsDelineated by facilityGrossly abnormal results that require immediate provider notificationLO 12.1 Diagnostic TestsRequired documentationName of primary care provider notifiedDate and time notifiedResults of test reportedProvider’s responseNo new ordersNew orders receivedLO 12.1 Diagnostic TestsFailure to communicate lab results as indicatedMay constitute nursing negligenceFollow facility chain-of-command policy if unable to reach providerLO 12.2 CHART EVALUATIONSLO 12.2 Chart EvaluationsChart evaluationsProvide mechanism for determining when health promotion and disease prevention interventions neededScreening tests/examsImmunizationsBased on gender, age, personal and family health historyImproves adherence to practice guidelinesLO 12.2 Chart EvaluationsUse of guideline remindersPatient has right to refuseDocument refusalProvider uses clinical judgment for recommendationsLO 12.3 ADDENDA TO A NURSE NOTELO 12.3 Addenda to a Nurse NoteAddendum = late entryUsed to add information omitted from original noteIncludes information about actual date and time of occurrence LO 12.4 PRINTING A NURSE NOTELO 12.4 Printing a Nurse NoteRarely requiredNurse note may be printed when transferring patient to another facility without EHRFollow facility policy for release of recordsLO 12.5 EXPORTING AND PRINTING THE CHARTLO 12.5 Exporting and Printing the ChartLegal considerationsThe Medical Records Confidentiality Act of 1995First comprehensive federal legislation protecting personal health informationRequires individuals to consent to release of health information for treatment or payment Individual state laws also regulate confidentiality of health recordsIn most cases, patient health records can only be released to others with the patient’s consentLO 12.5 Exporting and Printing the ChartRelease of recordsHealthcare facilities have ‘release of records’ formsPrivacy of recordsFederal law requires healthcare providers to employ security measures to ensure privacy of protected health information during electronic transmission