Questions On Health Records

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1. What is the primary purpose of a practice’s health record? The primary purpose of a health record is to document care received, including the steps taken to identify a diagnosis or problem and to treat it. 2. What record purpose is associated with each of the following? a. Medical assistant records the height, weight, and vital signs of a patient? Document care /services provided b. The results of the effectiveness of a new drug involved in a clinical research trial are reported to the study coordinator? Communicate with other health care providers and/or provide data for public health and health policy c. Penicillin is not prescribed for a patient because the allergy list indicates the patient will have a reaction to it? Provide…show more content…
Healthcare decisions may have been made based on content before the correction was inserted. A computer audit trail associated with the EHR will provide, if required, information about when specific entries were made, what information was available at what time, who made the correction. 11. Give two examples of abbreviations on the Joint commission “Do Not Use” list and explain why each should not be used. • “U” or ”u” for unit can be mistaken for “0”, the # four or “cc” • “IU” can be mistaken for “IV” or the # 10 12. What are three alternatives for recording signatures in an electronic record? a. If the system has an electronic signature pad similar to those found in some retail stores, the patient or care provider can use the “pen” to sign on the pad’s window in the designated box. b. Another option is to assign a computer key or keys that when used, provides a signature. The key or keys must be used only by the assigned provider. c. A third option is to continue using paper documents and then to scan the signed document into the electronic record for retention and

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