Electronic Health Records (EHR) Basics Exam
questions and answers
What is the purpose of medical documentation?
Medical record documentation is required to record pertinent facts, findings, and observations about an
individual's health history; important element contributing to high quality of care
What do medical records facilitate?
- the ability to evaluate and plan the pt's immediate treatment and monitor his/her healthcare
- communication and continuity in care
- accurate and timely claims review and payment
- collection of data for research and education
Why is it important properly document?
because physicians have contractual obligations, many insurance companies require reasonable
documentation that services are consistent with the insurance coverage being provided; it is important
that your documentation and exam matches your exam code
What is an Electronic Health Record (EHR)?
electronic version of a pt's medical history that is maintained by the provider over time and may include
all of the key administrative clinical data relevant to that person's care under a particular provider
What do EHR provide healthcare providers with?
demographics, inventory and orders, clinic notes, e-prescribing, and accounting
What do EHR clinical notes include?
medical record of pt visits; images and lab results; list of diagnoses, medications, allergies, health
history; referral management; coding based on documentation
What are the advantages of using EHR systems?
1. clear and concise documentation - avoids illegible handwriting, reduced risk of transcription errors,
audit protection
2. tracking pt care - easily access previous examination findings (VA, refraction, IOP, ocular health)
3. instrument integration - easily access and incorporate images in a pt's chart
4. letter writing - pt encounter summary, provider letters, transmission (print, fax, direct message)
5. e-prescribing - electronically submit a medication, database for faster prescribing, provides
connectivity to pt's pharmacy, insurance formulary (drug coverage), pt's drug-drug interactions, pt's
drug-allergy interactions
6. pt educations - automated to provide resources for the provider to give to the pt regarding their
diagnoses
7. pt communication - intra-practice communications from provider/staff to the pt increase pt's
questions and answers
What is the purpose of medical documentation?
Medical record documentation is required to record pertinent facts, findings, and observations about an
individual's health history; important element contributing to high quality of care
What do medical records facilitate?
- the ability to evaluate and plan the pt's immediate treatment and monitor his/her healthcare
- communication and continuity in care
- accurate and timely claims review and payment
- collection of data for research and education
Why is it important properly document?
because physicians have contractual obligations, many insurance companies require reasonable
documentation that services are consistent with the insurance coverage being provided; it is important
that your documentation and exam matches your exam code
What is an Electronic Health Record (EHR)?
electronic version of a pt's medical history that is maintained by the provider over time and may include
all of the key administrative clinical data relevant to that person's care under a particular provider
What do EHR provide healthcare providers with?
demographics, inventory and orders, clinic notes, e-prescribing, and accounting
What do EHR clinical notes include?
medical record of pt visits; images and lab results; list of diagnoses, medications, allergies, health
history; referral management; coding based on documentation
What are the advantages of using EHR systems?
1. clear and concise documentation - avoids illegible handwriting, reduced risk of transcription errors,
audit protection
2. tracking pt care - easily access previous examination findings (VA, refraction, IOP, ocular health)
3. instrument integration - easily access and incorporate images in a pt's chart
4. letter writing - pt encounter summary, provider letters, transmission (print, fax, direct message)
5. e-prescribing - electronically submit a medication, database for faster prescribing, provides
connectivity to pt's pharmacy, insurance formulary (drug coverage), pt's drug-drug interactions, pt's
drug-allergy interactions
6. pt educations - automated to provide resources for the provider to give to the pt regarding their
diagnoses
7. pt communication - intra-practice communications from provider/staff to the pt increase pt's
