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Availability - ✔✔Provider needing access to medical record
Ensure EHR Certification - ✔✔hospital meaningful use of eligibility
behavioral Health - ✔✔extensive social services documentation
Keep the original entry, enter the correct information, and sign/date the
change - ✔✔correcting documentation errors
EHR - ✔✔Primary data source
24 hours - ✔✔H&P documented after admission
History of present illness - ✔✔documentation of symptoms in the H&P
30 Days - ✔✔completed discharge summary post discharge
Computerized Physician Order Entry - ✔✔CPOE
Patient agrees to specific services - ✔✔consent to treatment form
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, Documentation of care, treatment & therapeutic response - ✔✔progress
notes
accountability - ✔✔CIO directs action
accountability - ✔✔Data stewards take action
protection - ✔✔data breaches, confidentiality, security concerns
cloud storage - ✔✔secure remote access
accuracy - ✔✔reducing error
Centralized Model - ✔✔one data repository
HIPAA - ✔✔requires CEs to develop/implement electron transaction
standards
NPBD- National Practitioner Data Bank - ✔✔Stores provider licensure and
credential status
CMS- Centers for Medicare and Medicaid Services - ✔✔requires data for
end-stage renal disease
access to back-up date to restore impact documents - ✔✔response needed
after system shut down due to breach
patient portal - ✔✔allows patient to add information for provider to see
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