Electronic Health Records

Which description best defines the electronic health record (EHR)? An electronic stand-alone database implemented and used in hospitals An electronic version of the traditional paper record created and used by the healthcare provider An electronic record of patient health information created by encounters across multiple settings An electronic version of a patient's medical record used in the clinical setting An electronic record of patient health information created by encounters across multiple settings ----------------------------------- The EHR is an electronic record of patient health information produced by encounters in one or more care settings. Every person will have a birth to death (and even postmortem) record of health-related information in electronic form from multiple sources, such as physician office visits, inpatient and outpatient hospital encounters, medications, allergies, and multiple other medical services to support care. All other answers refer to a single facility use, which is not the EHR but a potential component of the EHR. A health care provider is in the client's room documenting in the electronic health record (EHR). A family member is looking over their shoulder to get a view of the documentation. What action should the provider do first to ensure confidentiality and security of the record? Close the electronic health record immediately Continue documenting and provide copies to the family member Continue documenting in the record Take the family member to the nurse's station for assistance Close the electronic health record immediately ----------------------------------- Close the electronic health record immediately. Health care providers have a responsibility to protect health information, professionally, ethically, and legally. The family member is not an authorized user and has no reason to review documentation in the client's chart. A nurse on the medical-surgical unit reviews abnormal lab results in the client's electronic health record (EHR). Which step indicates that the nurse has processed this information appropriately? The nurse waits for the printed copy of the results before calling the provider The nurse reports the results to the provider The nurse contacts the family to report the results The nurse calls the supervisor with the results The nurse reports the results to the provider ------------------------------- If information obtained from the EHR is abnormal, the nurse should report abnormal information to the provider. It is a HIPAA violation to contact the family without prior authorization from the patient. You do not need a printed copy as the EHR is providing the results. The supervisor does not need to be called with abnormal lab results. Drag the correct term to match with the descriptions given below: _______ may be limited to one location or one practice and it may not contain additional health information like nursing notes, insurance and billing details, or lab and diagnostic data. ______ is another term used to describe an EMR. ________ is information about one's health that is designed to be managed by clients. It is designed to be set up, accessed, and managed by individual clients and the information is usually added by the client. Electronic Medical Record (EMR) Electronic Patient Record Personal Health Record (PHR) Electronic Medical Record (E