Note:
1. Plagiarism check2. APA 7th Edition
3. Citations & References must
4. Information taken from PPT slides should also be cited with slide numbers.
Lab #4
Answer the following questions for the lab, making sure to answer these DIRECTLY in the space provided. Do not alter the Word document in any way. If this is not followed, there is an automatic mark of zero given.
Use the PowerPoint slides and conduct any internet searches if required. Remember that a great paper will go above and beyond what I am asking with extra examples and references added.
Any external references, including the e-book or slides, must be cited using APA as a guide. Don’t forget to include in-text citations that show me specifically where your reference was used to provide background to your answer(s). Use a separate page at the end of the lab labeled “References” to list your references. If APA is not properly used, marks will be deducted.
Use default paragraph settings and format.
Also, list the answers underneath the question so that I am able to see which question you are answering.
Part 1 (15 points)
When there is a breach of privacy by a covered entity, a resolution agreement is put in place. Describe what a covered entity is, along with two examples, and explain two things that are required to satisfy certain requirements in this agreement.
150 to 250 words
Part 2 (10 points)
Research two examples where there have been cases of protected health information breaches anywhere in the world, and fully explain what happened during each of the examples, providing as much detail as possible, including the financial ramifications (if any).
150 to 250 words
Part 3 (10 points)
Describe what structured and unstructured data is, along with two healthcare-related examples of each.
150 to 250 words
Part 4 (10 points)
Describe what a flowsheet is, and give a practical healthcare example where a flowsheet is used to provide preventative healthcare-related advice for a patient.
INFO-6060 – Electronic Health Records
Lab #4
Answer the following questions for the lab, making sure to answer these DIRECTLY in the space provided.
Do not alter the Word document in any way. If this is not followed, there is an automatic mark of zero
given.
Use the PowerPoint slides and conduct any internet searches if required. Remember that a great paper will
go above and beyond what I am asking with extra examples and references added.
Any external references, including the e-book or slides, must be cited using APA as a guide. Don’t forget to
include in-text citations that show me specifically where your reference was used to provide background to
your answer(s). Use a separate page at the end of the lab labeled “References” to list your references. If
APA is not properly used, marks will be deducted.
Use default paragraph settings and format.
Also, list the answers underneath the question so that I am able to see which question you are answering.
Part 1 (15 points)
When there is a breach of privacy by a covered entity, a resolution agreement is put in place.
Describe what a covered entity is, along with two examples, and explain two things that are
required to satisfy certain requirements in this agreement.
Part 2 (10 points)
Research two examples where there have been cases of protected health information breaches
anywhere in the world, and fully explain what happened during each of the examples, providing
as much detail as possible, including the financial ramifications (if any).
Part 3 (10 points)
Describe what structured and unstructured data is, along with two healthcare-related examples of each.
Part 4 (10 points)
Describe what a flowsheet is, and give a practical healthcare example where a flowsheet is used to
provide preventative healthcare-related advice for a patient.
Chapter 6
Privacy, Security, and Legal Aspects
of the EHR
© Paradigm Education Solutions
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Learning Objectives
6.1
6.2
6.3
6.4
6.5
6.6
Define Health Insurance Portability and Accountability Act of 1996
(HIPAA), specifically the Administrative Simplification provisions and
the date enacted.
Identify who is and who is not considered to be a covered entity under
HIPAA.
Identify the basic principles of the Privacy Rule and differentiate
between when disclosure of protected health information is permitted
and when it is not permitted.
Demonstrate release of information (ROI) functions carried out by
health information management (HIM) staff in the electronic health
record (EHR) environment.
Demonstrate how to produce an accounting of disclosures log.
Discuss the concept of “minimum necessary” as it relates to the release
of health information.
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Learning Objectives, Continued
6.7
6.8
6.9
6.10
6.11
6.12
6.13
6.14
Explain the enforcement and penalty process for violations of HIPAA
privacy and security regulations.
Discuss the HIPAA Breach Notification Rule.
State the two primary purposes for the development of the security
standards of HIPAA.
List the major sections of the standards of the HIPAA Security Rule and
provide safeguard examples that apply to each section.
Discuss the difference between required and addressable
implementation specifications.
Explain why the 21st Century Cures Act is one of the most significant
acts regarding EHR use and exchange.
Discuss the purpose of the United States Core Data for Interoperability
(USCDI) and give examples of the data classes and data elements.
Define information blocking and give examples of what is and is not
considered information blocking.
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Introduction
• EHR users must understand and follow laws and
regulations regarding the privacy, safety, and security of
health information.
• Federal legislation provides guidance about the release and
security of:
– Protected health information (PHI) in paper health records
– Identifiable EHR patient information, known as electronic
protected health information (ePHI)
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6.1 Health Insurance Portability and
Accountability Act of 1996
• The Health Insurance Portability and Accountability
Act of 1996 (HIPAA) includes provisions that affect all
healthcare facilities.
– Allows for health insurance to be “portable”
– Addresses the confidentiality of medical records
– Sets standards for:
• Health information privacy and security
• Efficiency and effectiveness of healthcare systems (Sections
261–264, the Administrative Simplification Provisions)
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6.1 Health Insurance Portability and
Accountability Act of 1996, Continued
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6.2 HIPAA Privacy Rule
• 2000: US Department of Health and Human Services (HHS)
published the Privacy Rule
– Intended to define:
• Protected health information
• The entities and circumstances in which it may be used or
disclosed by covered entities
• 2013: HHS modified the HIPAA Privacy, Security, and
Enforcement Rules to align with the Health Information
Technology for Economic and Clinical Health (HITECH) Act
• 2020: Office for Civil Rights and HHS proposed changes to
the Privacy Rule
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6.2 HIPAA Privacy Rule, Continued
• The Privacy and
Security Rules
apply to covered
entities: healthcare
providers, health
plans, and
healthcare
clearinghouses
transmitting health
information in an
electronic format.
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6.2 HIPAA Privacy Rule, Continued
• Noncovered entities do not have to comply with the
Privacy and Security Rules.
– Workers’ compensation carriers
– Employers
– Marketing firms
– Life insurance companies
– Pharmaceutical manufacturers
– Casualty insurance carriers
– Pharmacy benefit management companies
– Crime victim compensation programs
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6.2 HIPAA Privacy Rule, Continued
• Types of health information classified under the Privacy
Rule:
– PHI
– Individually identifiable health information
– Deidentified health information
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6.2 HIPAA Privacy Rule, Continued
• PHI: information, including demographic data, that:
– Identifies the individual, or for which there is a reasonable
basis to believe that the information can be used to identify
the individual
– Relates to at least one of the following:
• The individual’s past, present, or future physical or mental
health condition
• The provision of health care to the individual
• The past, present, or future payment for the provision of health
care to the individual
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6.2 HIPAA Privacy Rule, Continued
• Types of PHI
– Name
– Address
– Any dates (except years
that are directly related to
the individual, such as
birth date)
– Telephone number
– Fax number
– Social Security number
– Medical record number
– Health plan beneficiary
number
– Account number
– Certificate/license number
– Vehicle identifiers
– Device identifiers or serial
numbers
– Email address
– Digital identifiers
– IP addresses
– Biometric elements
– Full face photographic
images
– Other identifying numbers
or codes
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6.2 HIPAA Privacy Rule, Continued
• Deidentified health information: neither identifies an
individual nor provides a reasonable basis to identify an
individual
– Use not restricted by the Privacy Rule
– Primarily used for summary purposes, e.g.:
• Number of patients from a ZIP code
• Number of patients who recently had a cavity
• Number of physical therapy home care visits
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6.2 HIPAA Privacy Rule, Continued
Basic Principles of the Privacy Rule
• A covered entity may not use or disclose PHI except either:
1. As the Privacy Rule permits or requires, or
2. As the individual who is the subject of the information (or
the individual’s personal representative) authorizes in
writing
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6.2 HIPAA Privacy Rule, Continued
Required Disclosures
• A covered entity must
disclose PHI to:
1. An individual (or their
personal representative),
specifically when he or she
requests access to, or an
accounting of disclosures
of, their PHI
2. HHS, specifically during a
compliance investigation,
review, or enforcement
action
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6.2 HIPAA Privacy Rule, Continued
Permitted Disclosures
• Health information can be used and/or disclosed without
prior patient authorization:
– To the individual patient
– For treatment purposes*
– For payment purposes*
– For healthcare operations*
*These three disclosures are known collectively as treatment,
payment, healthcare operations (TPO).
(Continued)
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6.2 HIPAA Privacy Rule, Continued
• Health information can be used and/or disclosed without
prior patient authorization:
– Incidental to an otherwise permitted use or disclosure
– For public interest and benefit activities
– As a limited data set for purposes of research, public
health, or healthcare operations
• PHI from which certain specified direct identifiers of
individuals and their relatives, household members, and
employers have been removed
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Consider This
A teenage patient brought to the emergency department (ED)
of a hospital drifts in and out of consciousness. The ED
physician suspects an adverse event from a medication the
patient is taking or a possible drug overdose. The ED
physician learns that the patient takes medications that have
been prescribed by the patient’s primary care physician.
Because the patient’s EHR is interoperable with the hospital’s
EHR, the ED physician is able to access the medications
prescribed for the patient. How does permitted disclosure of
health information in the Privacy Rule allow the patient to
receive the necessary care? What could happen if the patient
needs to wait while the hospital seeks authorization to
release her information?
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6.2 HIPAA Privacy Rule, Continued
Release of Information (ROI)
• Rules and regulations related to the release of PHI are the
same for a paper record and an EHR.
• The ROI process is more streamlined in an EHR
environment.
– Physical records do not need to be located.
– Records can be printed, saved to digital storage, or emailed
directly from the EHR.
– Records can be released faster.
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6.2 HIPAA Privacy Rule, Continued
Accounting of Disclosures
• Per the Privacy Rule, a
patient has the right to
receive an accounting of
disclosures of their PHI
made by the covered
entity.
• ROI software, as part of
the EHR system, produces
these documents.
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6.2 HIPAA Privacy Rule, Continued
Privacy Rule and State Laws
• State laws that contradict the Privacy Rule are overruled by
the federal requirements unless an exception applies.
Minimum Necessary Concept
• Minimum necessary: covered entities must make
reasonable efforts to limit the use of, disclosure of, and
requests for the minimum amount of PHI necessary to
accomplish the intended purpose
• Required by the Privacy Rule
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6.3 Privacy Rule Enforcement
• The HHS Office
for Civil Rights
(OCR) enforces
HIPAA Privacy
and Security
Rules.
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6.3 Privacy Rule Enforcement, Continued
• Two categories of Privacy Rule violations:
– Civil
• Penalties of $100-$50k per failure
– Criminal
• Penalties up to $250k and up to 10 years of prison
• The major difference between civil and criminal violations
involves the intent behind the violation.
– Mistaken vs. knowing
© Paradigm Education Solutions
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6.3 Privacy Rule Enforcement, Continued
• Resolution agreement: a contract signed by the federal
government and a covered entity in which that entity
agrees to:
– Perform certain obligations (e.g., staff training regarding
privacy and confidentiality)
– Send reports to the federal government for a certain time
period (typically three years)
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6.4 Breach Notification Rule
• Breach: an impermissible use or disclosure under the
Privacy Rule that compromises the security or privacy of
PHI and poses significant risks to the affected individual
– Financial risks, reputational risks, other identified harm
• Following a breach, covered entities and their business
associates must notify:
– Affected individuals
– HHS
– The media (in certain circumstances)
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6.4 Breach Notification Rule, Continued
Notice to Individuals Requirement
• Written notifications must be provided following the
discovery of a breach and include:
1. A description of the breach
2. A description of the types of information involved in the
breach
3. The steps affected individuals should take to protect
themselves from potential harm
4. A brief description of what the covered entity is doing to
investigate the breach, mitigate the harm, and prevent
further breaches
5. Contact information for the covered entity
© Paradigm Education Solutions
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6.4 Breach Notification Rule, Continued
Notice to the Media Requirement
• Covered entities must provide notice to the media of a
breach affecting more than 500 residents of a state or
jurisdiction.
– Press release to media outlets serving the affected area
– Must include the same information required for the
individual notice
© Paradigm Education Solutions
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6.4 Breach Notification Rule, Continued
• The most often investigated HIPAA compliance issues:
1. Impermissible uses and disclosures of PHI
2. Lack of safeguards of PHI
3. Lack of patient access to their PHI
4. Lack of administrative safeguards of ePHI
5. Uses or disclosures of more than the minimum necessary
PHI
© Paradigm Education Solutions
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6.4 Breach Notification Rule, Continued
• The most common types of covered entities required to
take corrective action:
1. Private practices
2. General hospitals
3. Outpatient facilities
4. Pharmacies
5. Health plans (group health plans and health insurance
issuers)
© Paradigm Education Solutions
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6.4 Breach Notification Rule, Continued
Cases of Protected Health Information Breaches
• 2018: Anthem, Inc.
– Hacker accessed 78.8 million record database
• 2017: Lifespan Health System
– Laptop containing ePHI of more than 20,000 patients stolen
• 2016: Athens Orthopedic Clinic
– PHI database of over 200,000 patients stolen
• 2015: Primera Blue Cross
– Hacker accessed information of more than 10 million
individuals
© Paradigm Education Solutions
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6.5 HIPAA Security Rule
• The Security Standards for the Protection of Electronic
Protected Health Information were developed to address
the security provisions of HIPAA.
– Known as the Security Rule
– Pertain exclusively to electronic health information
• As the United States moves toward its goal of a
Nationwide Health Information Network and a greater
use of EHRs, protecting the confidentiality, integrity, and
availability of ePHI becomes even more critical.
© Paradigm Education Solutions
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6.5 HIPAA Security Rule, Continued
Objectives of the Security Rule
• Each covered entity must:
1. Ensure the confidentiality, integrity, and availability of ePHI
that it creates, receives, maintains, or transmits
2. Protect against any reasonably anticipated threats and
hazards to the security or integrity of ePHI
3. Protect against reasonably anticipated uses or disclosures of
such information that are not permitted by the Privacy Rule
4. Ensure compliance by the workforce
© Paradigm Education Solutions
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6.5 HIPAA Security Rule, Continued
Major Differences between the Privacy and Security Rules
• The rules are closely aligned, but there are two areas of
distinction:
– The Privacy Rule applies to all PHI; the Security Rule covers
only ePHI.
– The Privacy Rule contains minimum security aspects for PHI
protection; the Security Rule provides comprehensive
security requirements.
© Paradigm Education Solutions
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6.5 HIPAA Security Rule, Continued
Sections of the Security Rule
• General Rules
– States general covered entity requirements
• Administrative Safeguards
– Includes the assignment or delegation of security
responsibility to an individual and the need for security
training for employees and users
• Physical Safeguards
– Includes mechanisms necessary to protect electronic
systems from threats, environmental hazards, and
unauthorized intrusion
(Continued)
© Paradigm Education Solutions
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6.5 HIPAA Security Rule, Continued
• Technical Safeguards
– Covers automated processes
used to protect and control
access to data
• Organizational Requirements
– Includes standards for
business associate contracts
and requirements for group
health plans
• Policies and Procedures and Documentation Requirements
– Addresses implementation of reasonable and appropriate
policies and procedures to comply with the Security Rule
standards
© Paradigm Education Solutions
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6.5 HIPAA Security Rule, Continued
• The Security Standards
Matrix assists covered
entities in assessing
their compliance with
the Security Rule.
– A required standard
(R) must be met.
– An addressable
standard (A) should
be met if it is a
reasonable and
appropriate safeguard
in the entity’s
environment.
© Paradigm Education Solutions
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6.5 HIPAA Security Rule, Continued
EHR System Security
• EHR systems can track and record user activity.
• Once clinical documentation has been entered and
authenticated, documented entries cannot be modified.
• Attempts to change a health record can easily be identified
by an administrator.
© Paradigm Education Solutions
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6.5 HIPAA Security Rule, Continued
HIPAA Security Rule Enforcement
• Same process as Privacy Rule enforcement
• Organizations have bolstered their efforts by:
– Reducing risk through network or enterprise data storage:
a centralized system that businesses use for managing and
protecting data
(Continued)
© Paradigm Education Solutions
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6.5 HIPAA Security Rule, Continued
• Organizations have bolstered their efforts by:
– Encrypting ePHI
– Maintaining administrative and physical safeguards on the
devices and media that handle ePHI
– Raising employee awareness of security and good data
stewardship: the authority and responsibility associated
with collecting, using, and disclosing health information
© Paradigm Education Solutions
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Consider This
An employee of the State Department of Health and Social Services left
a portable electronic storage device (USB drive) in a car that was later
stolen. The USB drive contained ePHI, so the State Department of
Health and Social Services submitted a report to the OCR, as all
covered entities are required to do when a breach of health
information security has occurred. When the OCR investigated, it
found evidence that the department did not have adequate policies
and procedures in place to safeguard ePHI. In addition, the department
had not completed a risk analysis, implemented sufficient risk
management measures, completed security training for its workforce
members, implemented device and media controls, or addressed
device and media controls or encryption, as required by the HIPAA
Security Rule. Does the State Department of Health and Social Services
have to follow the HIPAA Security Rule? Why? Is there a possibility
that the department would be fined in this scenario? What do you
think the findings of the OCR should be?
© Paradigm Education Solutions
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6.6 21st Century Cures Act and Final Rule
• 21st Century Cures Act (2016): one of the most significant
acts to address patient access to electronic medical records
and the exchange and use of health information
• Final Rule: sets the standards for interoperability to
promote patient access and control of their ePHI
• The United States Core Data for Interoperability (USCDI): a
required, standardized set of health data for nationwide,
interoperable health information exchange
– Version 1: May 2020
– Version 2: July 2021
© Paradigm Education Solutions
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6.6 21st Century Cures Act and Final
Rule, Continued
© Paradigm Education Solutions
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6.6 21st Century Cures Act and Final
Rule, Continued
• The 21st Century Cures Act defines and disallows
information blocking:
– A practice by a health IT developer of certified health IT,
health information network, health information exchange, or
healthcare provider that, except as required by law or
specified by the Secretary of HHS as a reasonable and
necessary activity, is likely to interfere with access, exchange,
or use of ePHI
• This part of the Cures Act prevents restricting access to or
abusing electronic health information.
© Paradigm Education Solutions
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Chapter 7
Clinical Documentation
© Paradigm Education Solutions
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Learning Objectives
7.1
7.2
7.3
7.4
7.5
7.6
7.7
Differentiate between structured and unstructured data
and identify examples of each.
Explain manual and automated methods of data collection.
Explain the clinical documentation cycle and give
examples of its use in inpatient, outpatient, and long-term
care settings.
Identify the elements of a history and physical
examination.
Discuss the use of templates in the EHR.
Discuss documentation in inpatient, outpatient, and
skilled nursing provider settings.
Identify the concerns related to cloned notes.
© Paradigm Education Solutions
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Learning Objectives, Continued
7.8
7.9
Define e-prescribing, including its benefits and challenges.
Modify an eprescription and override a drug allergy
notification in the EHR.
7.10 Describe the benefits of computerized provider order
entry (CPOE), portable medical orders, and the electronic
medication administration record (eMAR).
7.11 Demonstrate how to enter progress notes, modify
patients’ eprescriptions, and override drug allergy
notifications in the EHR system.
7.12 Discuss the purpose of the Minimum Data Set (MDS) in a
skilled nursing and rehabilitation provider setting.
© Paradigm Education Solutions
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Introduction
• Healthcare staff enter patient and clinical data to create the
electronic health record (EHR).
• Examples of clinical data:
– History and physical examination
– Progress notes by all clinicians
– Immunization information
– Laboratory test results
– Medications
© Paradigm Education Solutions
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7.1 Clinical Documentation in the EHR
• Clinical documentation, also known as clinical inputs,
contains data related to a patient’s clinical status that is
entered into the EHR.
• Structured data: stored in a specific, organized fashion
within a database
– Date of birth, sex, race, lab results, International
Classification of Diseases (ICD) codes
• Unstructured data: stored in a free-form format; does not
adhere to a pre-defined or organized model within a
database
– Progress notes, test interpretations, operative reports
© Paradigm Education Solutions
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7.1 Clinical Documentation in the EHR,
Continued
• Data collection for the EHR
occurs through a combination of
manual and automated methods.
• Manual data collection: staff
member or provider enters data
into a record
• Automated data collection:
data from the initial patient
encounter is automatically
copied over to each new patient
encounter using an automated
data capture
© Paradigm Education Solutions
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7.2 Clinical Documentation Cycle
© Paradigm Education Solutions
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7.3 Inpatient Clinical Documentation
• A history and physical exam (H&P) is part of all inpatient
encounters.
– Valuable tool in identification of diagnoses
– First step in developing a plan of care
– Consists of two main elements: subjective and objective
© Paradigm Education Solutions
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7.3 Inpatient Clinical Documentation,
Continued
• A subjective element is based on personal reporting and
opinions and may be biased or difficult to measure.
• The history is the subjective element of the H&P.
– Chief complaint: the patient’s stated reason for seeking
health services
– History of present illness
– Past medical issues
– Allergies
– Medications currently prescribed to the patient
– Family and social histories
© Paradigm Education Solutions
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7.3 Inpatient Clinical Documentation,
Continued
• The physical examination is the objective element of the
H&P.
– Based on facts and not subject to interpretation
– Conducted by nursing or medical staff
– Includes:
• An investigation of the patient’s body systems, known as the
review of systems (ROS)
• An assessment of the patient’s condition
• The creation of a treatment plan to remedy the patient’s
condition
© Paradigm Education Solutions
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7.3 Inpatient Clinical Documentation,
Continued
• The ROS entails the following system assessments:
1. General
2. Vital signs
3. Head, ears, eyes, nose, throat (HEENT)
4. Respiratory
5. Cardiovascular
6. Abdominal
7. Gastrointestinal
8. Genitourinary
9. Musculoskeletal
10. Neurologic
© Paradigm Education Solutions
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7.3 Inpatient Clinical Documentation,
Continued
• Many of the clinical inputs to an EHR system are
accomplished using a template: a preformatted file that
provides prompts to obtain specific, consistent
information.
• Template advantages:
– Required fields indicated
– Consistent data gathering
– Efficient structured data entry
– Immediate data population
– Reduced transcription expense
– Easy access to data
– Faster and more precise data reporting and analysis
© Paradigm Education Solutions
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7.3 Inpatient Clinical Documentation,
Continued
• Specialized templates are tailored to specific
documentation needs.
© Paradigm Education Solutions
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7.3 Inpatient Clinical Documentation,
Continued
• Care plan: a patient’s road map to better health
– Also known as a treatment plan or plan of care
– Developed and executed by the entire clinical team in
conjunction with the patient
© Paradigm Education Solutions
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7.3 Inpatient Clinical Documentation,
Continued
• Nurses spend a considerable amount of time documenting
care and treatment.
• Nurses conduct an admission assessment after the
patient’s arrival to the hospital room, which includes:
– General admission data
– Patient history
– Physical assessments of all major body systems
– Spiritual, cultural, and social histories and perspectives
© Paradigm Education Solutions
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7.3 Inpatient Clinical Documentation,
Continued
• Progress notes: the portion of the health record in which
healthcare providers document the patient’s progress, or
lack thereof, in relation to the goals of the care plan
• A customized template may help facilitate progress note
documentation in EHRs
– Caters to certain disciplines and specialties
– Lessens data entry time
– Ensures the inclusion of all pertinent data elements
© Paradigm Education Solutions
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Consider This
Dr. Calvin Sebold’s progress note for 9/12/2030, 6:20 a.m.:
Patient examined and found in no acute distress. Patient has no complaints at this
time. Lab values reviewed and all within normal limits. Continue current plan of
treatment.
Nurse Bethany Akin’s nurse’s note for 9/13/2030, 4:50 a.m.:
Patient complains of nausea and headache. Vital signs: BP 180/101, T 101.8°, P 87,
R 12. Resident telephoned and ordered CBC. Abnormal WBC of 9000. Resident
telephoned and ordered urine culture. Awaiting results.
Dr. Sebold’s progress note for 9/13/2030, 7:10 a.m.:
Patient examined and found in no acute distress. Patient has no complaints at this
time. Lab values reviewed and all within normal limits. Continue current plan of
treatment.
How does Dr. Sebold’s progress note conflict with Nurse Akin’s progress note? If
you compare Dr. Sebold’s progress notes on two different days, you will note that
the documentation is identical, indicating the use of a cloned progress note.
© Paradigm Education Solutions
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7.3 Inpatient Clinical Documentation,
Continued
• Cloned progress note: a note partially or totally copied
from an existing progress note and updated by the
provider to include any new information
– Saves time, but can result in inaccurate or outdated
documentation
– Can complicate coding and negatively influence
reimbursement
© Paradigm Education Solutions
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7.3 Inpatient Clinical Documentation,
Continued
• The Office of the Inspector General (OIG) routinely audits
healthcare organizations’ billing and coding practices.
– Seeks to combat healthcare fraud, waste, abuse
– Establishes an annual Work Plan of areas of healthcare
documentation and billing practices to be addressed and
audited during the year
© Paradigm Education Solutions
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Consider This
The Emergency Care Research Institute (ECRI) conducted a
study looking at the frequency of cloning/copying and pasting
in a random sample of 239 EHR notes. The study indicated
that 10.8% of notes contained cloned material, and the
frequency varied by specialty. Endocrinology notes were the
highest, at 19.5% of notes containing cloned materials, and
cardiology was the lowest, at 1.9% containing copied
material. Obviously, cloning is a time-saving activity. However,
what problems could arise from cloned progress note
documentation?
© Paradigm Education Solutions
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7.3 Inpatient Clinical Documentation,
Continued
• e-Prescribing: EHR feature that allows providers to
electronically transmit medication orders
© Paradigm Education Solutions
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7.3 Inpatient Clinical Documentation,
Continued
• Benefits:
– Improved prescribing accuracy and efficiency
– Decreased potential for medication errors
– More accurate and timely billing
– Effective patient communication
– Alerts prescribers to drug interactions and patient
medication allergies
© Paradigm Education Solutions
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7.3 Inpatient Clinical Documentation,
Continued
• Challenges of e-prescribing
– Ordering controlled substances: a drug (primarily a
narcotic) declared by US federal or state law to be illegal for
sale or use by the public unless dispensed per a healthcare
provider’s prescription
• Controlled Substances Act of 1970: requires controlled
substances to be dispensed only with hard-copy or printed
prescriptions
• All states now permit e-prescribing for controlled substances,
but many EHR systems have not upgraded software to do so.
• Many providers are uncomfortable using e-prescribing for
frequently abused painkillers.
– Lack of interoperability between healthcare facility EHR
software and some pharmacy software
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Consider This
Prescriptions that have been handwritten by physicians or
other prescribers pose a number of potentially serious
problems. The combination of handwriting style and the use
of abbreviations can lead to difficulty in reading and filling the
prescription accurately. This can result in mistaken drug
names, dosages, and strengths. Another issue with
handwritten prescriptions is that they can be easily altered by
drug seekers. In light of these issues, how does the use of eprescribing decrease the potential for medication errors and
prescription forgeries?
© Paradigm Education Solutions
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7.3 Inpatient Clinical Documentation,
Continued
Managing Orders
• Computerized provider order entry (CPOE)
– Used to order medications, diagnostic tests, procedures,
treatments
– Needed for consultations, resuscitation, transfers, and
discharges
– Generates charges for billing
• Portable medical order: a type of medical order that is
entered into the EHR and then shared with other providers
– E.g., orders regarding life-sustaining treatments
© Paradigm Education Solutions
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Consider This
Patient Eleanor, who has a portable medical order for lifesustaining treatment, arrived via ambulance at a hospital
emergency room in acute heart failure and respiratory distress.
Eleanor’s daughter shared her mother’s portable medical order for
life-sustaining treatments with the EMTs, who then shared it with
the emergency room physician. The emergency room physician and
staff were made aware of Eleanor’s wishes and acted accordingly.
Eleanor’s portable medical order for life-sustaining treatments
indicated that she did not wish to be resuscitated in the event of a
cardiac arrest. When Eleanor subsequently suffered a cardiac
arrest in the emergency room, the emergency room physician and
staff honored her wishes and did not resuscitate her. If the
physician had not been made aware of Eleanor’s portable medical
order, what would have been the likely outcome?
© Paradigm Education Solutions
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7.3 Inpatient Clinical Documentation,
Continued
• Electronic medication administration record (eMAR):
documentation of medications administered to patients
– Benefits the patient and increases efficiency for the care
team
© Paradigm Education Solutions
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7.3 Inpatient Clinical Documentation,
Continued
• Flowsheet: a type of documentation tool used to record
patient-related values over time
– E.g., weight, fluid input, lab values, blood glucose levels
– Common flowsheets found in EHR documentation:
• Vital Signs Flowsheet
• Blood Sugar Values Flowsheet
• Intake and Output Flowsheet
© Paradigm Education Solutions
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7.3 Inpatient Clinical Documentation,
Continued
Therapy Documentation
• Four major types of therapy:
– Physical
– Occupational
– Speech
– Respiratory
• Therapists focus on activities of daily living (ADLs): the
fundamental skills one needs to be able to perform to
independently care for themselves.
– E.g., eating, bathing, dressing, toileting, mobility
• Therapists follow the clinical documentation cycle.
© Paradigm Education Solutions
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7.4 Outpatient Clinical Documentation
H&P
• The outpatient H&P consists of the subjective and objective
elements.
• However, the physician may conduct a complete ROS or a
selective ROS that focuses on the body systems involved
with the patient’s chief complaint(s).
• Outpatient H&P templates
– Several available
– Include fields to record the annual history and the physical
examination for patients who are well and asymptomatic
© Paradigm Education Solutions
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7.4 Outpatient Clinical Documentation,
Continued
Electronic Chart Note Templates
• Outpatient progress notes or chart notes are often templates
based on chief complaint or the reason for the visit.
• EHR Navigator examples of chief complaint templates:
– Abdominal Pain Chart Note
– Auto Accident Follow-up Chart Note
– Breast Cancer Chart Note
– CHF Chart Note
– Constipation Chart Note
– Headache Chart Note
– Knee Pain Chart Note
– Pediatric Otitis Media Chart Note
– UTI Chart Note
• Free text chart note
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7.4 Outpatient Clinical Documentation,
Continued
Electronic Superbill
• Also called an encounter form
• An itemized form that allows charges to be captured from
a patient visit
• Provider enters:
– Reason for visit
– Time and level of service rendered
– Testing performed in the office
© Paradigm Education Solutions
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7.4 Outpatient Clinical Documentation,
Continued
Outpatient Eprescription
• Process is the same as in the inpatient setting, except:
– Eprescriptions are transmitted to community pharmacies
rather than to the hospital’s pharmacy.
– Prescription refills are more prevalent in the outpatient
setting.
© Paradigm Education Solutions
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7.5 Skilled Nursing and Rehab Clinical
Documentation
• Skilled nursing and rehab documentation follows most of
the same requirements as an inpatient setting.
• Most notable documentation difference is the Minimum
Data Set (MDS), which is used to:
– Assess patients
– Drive reimbursement to the skilled nursing facility
© Paradigm Education Solutions
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7.5 Skilled Nursing and Rehab Clinical
Documentation
• The MDS is part of the federally mandated process for
clinical assessment of all residents in Medicare- and
Medicaid-certified nursing homes.
– Provides a comprehensive assessment of each resident’s
functional capabilities
– Helps nursing home staff identify health problems
– Used to derived a care plan
© Paradigm Education Solutions
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7.5 Skilled Nursing and Rehab Clinical
Documentation, Continued
© Paradigm Education Solutions
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